Efcacy of Intensive Phonatory-Respiratory

Treatment (LSVT) for Presbyphonia: Two

Case Reports
Fang-Ling Lu, Shannon Presley, and Becky Lammers, Denton, Texas
Summary: Objectives. Research evidence has shown that neither traditional voice therapy nor surgery was efca-
cious in managing age-related dysphonia, specically for more severe cases with pronounced fold atrophy or larger glot-
tal gaps. The purpose of this study was to examine the efcacy of intensive respiratory-phonatory treatment (Lee
Silverman voice treatment [LSVT]) for glottal incompetence associated with presbyphonia.
Study Design. Nonrandomized prospective study.
Methods. Two subjects with age-related vocal fold bowing received 4 weeks of the LSVT. Strobolaryngoscopic ex-
amination, phonatory function measurement, acoustical analyses, and perceptual judgments of voice were obtained at
baseline and 2 weeks posttreatment. Additional acoustic measures of phonatory function, including vocal intensity,
maximum phonation time, and pitch range, were also obtained during 16 treatment sessions.
Results. Both subjects exhibited signicant improvements in glottal closure, phonatory function, acoustic features,
and perceptual ratings of voice after treatment. Signicant changes of phonatory function measures were noticed rel-
atively early and remained steady throughout the course of treatment.
Conclusions. These ndings provide solid evidence that speakers with age-related vocal fold bowing and dysphonia
may improve glottal competence and related vocal function with neither laryngeal trauma nor maladaptive laryngeal
hyperfunction after the LSVT.
Key Words: PresbyphoniaGlottal incompetenceTreatment efcacyLSVT.
INTRODUCTION
The current number of Americans aged 65 and older is approx-
imately 41 million, more than one in every eight of the general
population.
1
The number of the elderly is expected to increase
by 3236% every decade during the next 20 years as a result of
the growing population of the elderly from the baby boomer
generation. The literature reports that roughly 2030% of the
elderly are affected by age-related vocal fold atrophy and bow-
ing, resulting in glottal incompetence and dysphonia (ie, pres-
byphonia). The impact of presbyphonia may be benign if
changes of laryngeal structures vocal function are gradual
and mild, but the condition almost certainly has a crippling
effect over time on the individuals health and social in-
teraction.
2,3
Reportedly, 13% of individuals aficted with
presbyphonia complained of a moderate to severe impact on
their quality of life.
4,5
With the fast growing rate of the older
population in the United States, it presents voice clinicians
with an inevitable reality and an urgent need to seek viable
treatment options for aging voice disorders.
Individuals with presbyphonia typically exhibit a wide array of
voice disturbances because of anatomical and physiological
changes in the aging laryngeal mechanism. Age-related changes
may be evident from gradual deterioration in the central
and peripheral nervous system control of the laryngeal
muscles, degenerative changes of muscle bers and mucosal tis-
sues, and declines in respiratory-phonatory coordination.
611
Laryngoscopic characteristics of presbylaryngis include vocal
fold atrophy and bowing, prominence of vocal processes,
edema, or glottal gap.
1218
The size of glottal gap may range
fromno observable gap to a large spindle-shaped gap, relatively
unmatched to the severity of vocal fold atrophy and bowing.
19,20
The mucosal wave of the aging vocal folds is reportedly
aperiodic and of reduced amplitude.
13,21
Perceptually,
presbyphonia is described as a voice of thin, weak, and hoarse
quality, increased breathiness, low pitch, diminished pitch
range, increased strain and unsteadiness, and at times with
vocal tremor.
2227
Acoustically, elderly voice is characterized
by higher perturbations of frequency (ie, jitter), amplitude (ie,
shimmer), and spectral noise, as well as uctuation of
fundamental frequency.
14,16,2731
Efcacious treatment for presbyphonia requires a multidisci-
plinary approach. Current rehabilitation protocol typically has
voice therapy as the rst line of treatment.
6,3234
When an
individual with presbyphonia fails to achieve satisfactory
progress through voice therapy, medical intervention is then
pursued to improve glottal closure. Thus far, surgical
procedures are not always desired by physicians or patients
because of their invasive nature and possible complications.
3538
Conventional voice therapy prescribed for presbyphonia may
include indirect approaches and direct therapy techniques. In-
direct approaches normally focus on patient education, vocal
hygiene, and elimination of causes of the voice disorder to
minimize any handicap.
39,40
Direct therapy techniques often
involve strengthening exercises or physiologically focused
techniques aiming to optimize vocal effectiveness via
respiratory-phonatory coordination. Afewcommonly practiced
Accepted for publication June 11, 2013.
Portions of this article were presented at the American Speech-Language-Hearing Asso-
ciation in Philadelphia, PA (2010) and the 6th Biennial Conference on Motor Speech in
Santa Rosa, CA (2012).
From the Department of Speech and Hearing Sciences, University of North Texas, Den-
ton, Texas.
Address correspondence and reprint requests to Fang-Ling Lu, Department of Speech
and Hearing Sciences, University of North Texas, 1155 Union Circle # 305010, Denton,
TX 76203-5017. E-mail: u@unt.edu
Journal of Voice, Vol. -, No. -, pp. 1-13
0892-1997/$36.00
2013 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2013.06.006
techniques include resonance and tone exercises, stretch and
ow, semioccluded vocal tract exercises, strengthening, vocal
function exercises, and resonant voice therapy, to name a few.
Through these approaches, the individual with presbyphonia is
expected to regain ability of producing the strongest clearest
voice without increasing muscle tension or vocal fold impact
stress.
6,32,34,4045
Conventional voice therapy for presbyphonia
requires multiple treatment sessions, typically 1 or 2 weekly
sessions spanning 1 to 2 months.
Numerous voice treatment studies have been published on ef-
cacy for presbyphonia or vocal fold bowing,
3,20,32,39,4648
which are briey summarized in Table 1. Five of seven studies
under review used traditional methods of voice therapy in one
or two treatment sessions per week. The total number of treat-
ment sessions conducted in these studies varied widely, ranging
from1 session to as many as 12 sessions. Although these studies
reported posttreatment improvements on subjective assessment
(eg, quality of life survey) and a few objective measures (eg,
maximum phonation time [MPT], airow measures), most ob-
jective measures such as acoustic analysis or laryngeal exami-
nation did not show signicant changes after therapy. In
contrast, two other studies using rigorous exercise-based behav-
ioral treatment yielded very promising results of glottal closure
and phonatory function in subjects with presbyphonia.
3,47
Ramig et al
3
reported signicant posttreatment improve-
ments of vocal intensity and vocal fold adduction in three el-
derly subjects aged 6870 years with presbyphonia when an
intensive respiratory-phonatory treatment program (ie, Lee Sil-
verman voice treatment [LSVT]) was applied. The LSVT was
originally designed to improve respiratory drive and vocal
fold adduction in patients of Parkinson disease (PD) by using
loud and effortful phonatory tasks. The LSVT program is rou-
tinely implemented in sixteen 60-minute treatment sessions
spanning a period of 4 weeks. Each treatment session typically
consists of intensive vocal fold exercise drills with copious rep-
etitions, high physical exertion, incorporation of complex tasks,
continuing calibration, and usage of shout-loud voice.
49,50
Vocal exercises in the LSVT focus on vocal loudness,
duration and pitch range of phonation, and assimilation of
functional speech in daily practices. In addition to in-house
treatment sessions, the LSVT protocol also requires individuals
to complete daily homework assignments during therapy and to
continue daily carryover exercises after treatment.
LaGorio et al
47
studied treatment efcacy for several subjects
of advanced age, between 58 and 82 years, and vocal fold bow-
ing who underwent a combination therapy of transcutaneous
neuromuscular electrical stimulation (NMES; VitalStim Ther-
apy),
51
and vocal exercises. The treatment protocol by LaGorio
et al
47
involves a 14-step series of progressive vocal exercises
paired with concurrent NMES. During treatment sessions, the
NMES electrodes are placed toward the cricothyroid membrane
and the superior laryngeal nerves intended to stimulate the cri-
cothyroid muscles during vocal exercises. The 14-step progres-
sive vocal exercises focus on duration, volume, and pitch range
of phonation, with the 1st to 11th steps of exercise targeting the
sustained phonation stimuli and the 12th to 14th steps on vari-
ous speech. The program is administered in fteen 60-minute
therapy sessions, including 2 training sessions and 13 full treat-
ment sessions, over a period of 3 weeks. Results shown in the
study by LaGorio et al indicate positive effects of the combined
therapy on increasing glottal closure and improving associated
phonatory function in the elderly subjects of vocal fold bowing.
The purpose of the present study was to provide an extensive
evaluation of LSVTefcacy for glottal incompetence and hypo-
functional voice related to presbylaryngis. In this study, quanti-
tative measurements of glottal gap size (GGS) and phonatory
function were conducted before, during, and after treatment.
Subjective evaluation of the laryngeal conguration and per-
ceptual voice rating was also conducted. Furthermore, this
study investigated if an increase of maladaptive laryngeal hy-
perfunction occurred as a result of the LSVT.
METHOD
Participants
Two patients were diagnosed with presbylaryngis by local oto-
laryngologists and referred to the university clinic for compre-
hensive voice evaluation and consideration of voice treatment.
These two patients were denoted as subject 1 and subject 2, re-
spectively, in this article.
Subject 1. Sixty-one-year-old female, a retired ofce worker,
complained of a weak and breathy voice when engaging in long
conversation and a moderate difculty of being heard over the
phone. The subject reported a history of asthma in the recent
6 years for which she was prescribed steroid-based inhalers
for treatment. She also had a lengthy history of airborne aller-
gies and year-round sinus problems since young adulthood.
The only medication taken at the time of the voice evaluation
was an antireux drug for suspected gastroesophageal reux
disease (GERD).
Subject 2. Eighty-eight-year-old male, a retired professor in
vocal studies, complained of a weak and breathy voice and
a great difculty to be understood by others during conversa-
tion. The subject had an unremarkable medical history except
for suspected GERD. His vocal difculty started approximately
5 years ago and had declined slowly over time.
Voice diagnostic assessment
Both subjects underwent a routine voice assessment including
a videostrobolaryngoscopic examination, acoustical analysis,
and perceptual judgment of voice quality. A screening of motor
speech function was also conducted to exclude potential con-
comitant speech disorders. Strobolaryngoscopic examination
was conducted during sustained vowel /i/ phonation at a habitual
level of pitch and loudness and during a pitch glide. The exam-
ination was performed by way of a 70-degree rigid scope
(model 9106; Kay Elemetrics, Lincoln Park, NJ), which was
coupled with a CCD Panasonics camera (model GP-KS152)
and a stroboscopic light source (RLS 9100; Kay Elemetrics).
Laryngoscopic images were captured and recorded on a com-
puter using a digital video recording system (model 9200C;
KayPENTAX, Lincoln Park, NJ) at the rate of 30 consecutive
frames per second. For acoustical analysis and perceptual audi-
tory assessment, the voice samples were obtained when each
Journal of Voice, Vol. -, No. -, 2013 2
TABLE 1.
Voice Treatment Outcomes of Presbyphonia Studies
References Nature of Study
Subject With
Presbyphonia or Vocal
Fold Bowing Voice Therapy Outcome Measures Results
Berg et al
32
Retrospective, chart
review
19 patients (6283 y) Vocal education,
resonance and tone
exercises, and vocal
function exercises;
approximately four
therapy sessions
across 5 mo
Patient-based
assessment per VRQOL
survey
Improvement on the
VRQOL score from
moderate to mild
dysphonia
Gartner-Schmidt and
Rosen
39
Retrospective, chart
review
275 patients (5597 y) Individually designed
therapy using indirect
approaches (eg, vocal
hygiene, patient
education, relaxation,
etc.) and direct therapy
techniques (eg,
resonant voice therapy,
Lessac-Madsen
resonant voice
program, ow
phonation,
semioccluded vocal
tract exercises, etc.); no
mention of treatment
schedule
Patient-based
assessment using the
VHI-10
Unsatisfactory treatment
outcomes, regardless
of voice therapy alone,
surgery alone, or the
combined treatment
Gorman et al
46
Prospective,
experimental
19 male patients (6078 y) Vocal function exercise
for 12 wk per weekly
sessions and daily
homework
assignments (ie, 12
treatment sessions
plus home exercises)
Glottal aerodynamic
measures (glottal
airow and subglottic
pressure) and MPT
measures
Signicantly longer MPT
and improvement on
some airow
measures, suggesting
improved glottic
closure
LaGorio et al
47
Prospective,
experimental
Seven patients (5881 y) Fourteen-step
progressive vocal
exercises paired with
NMES (VitalStim) per
daily 60-min sessions
for 3 wk (ie, 15
treatment sessions)
Acoustic analysis,
judgment of glottic
closure per
stroboendoscopic
examination,
pulmonary function
test, and patient-based
assessment using the
VHI
Signicant longer MPT
and improved VHI
scores, as well as
increased glottal
closure with less
supraglottic
compression;
insignicant changes
in pulmonary function
(Continued)
F
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,
e
t
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l
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f

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c
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TABLE 1.
(Continued)
References Nature of Study
Subject With
Presbyphonia or Vocal
Fold Bowing Voice Therapy Outcome Measures Results
Mau et al
20
Retrospective, chart
review
67 patients (5691 y) Vocal exercises adopted
fromthe LSVT focusing
on high pitch or loud
voice production, vocal
function exercises,
airow/resonance
exercises, resonant
voice, and stretch/ow
exercises; average 2.6
sessions (median, 2;
range, 17)
Clinician-based
assessment per FCMs
for voice (ASHA
National Outcomes
Measurement System)
and judgment of glottal
closure per
stroboendoscopic
examination
Eighty-ve percent
showed improved FCM
scores; less
improvement in cases
of larger glottic gaps or
pronounced vocal fold
atrophy
Ramig et al
3
Prospective,
experimental
Three patients (6870 y) LSVT per daily 60-min
sessions, four sessions
a week for 4 wk, plus
daily homework
assignments (ie, 16
treatment sessions
plus home exercises)
Vocal intensity measures
(SPL), laryngeal EMG,
subglottal pressure,
and judgment of glottal
closure per
stroboendoscopic
examination
Signicant increases in
SPL, subglottal air
pressure, and the rate
of thyroarytenoid
muscle modulation;
improved vocal fold
adduction
Sauder et al
48
Prospective,
experimental
Nine patients (6790 y) Practices of four
components in the
vocal function
exercises (MPT and
pitch glides using
specic pitch and
phonetic contexts)
twice daily for 6 wk;
also weekly 60-min
therapy for 6 wk to
review the progress
and practice extreme
forward focus and
breathsupport (ie, daily
home exercises plus six
treatment sessions)
Acoustic analysis,
patient-based
assessment per VHI
and patients self-
determined phonatory
effort, judgment of
glottal closure per
stroboendoscopic
laryngoscopic
examination, and
perceptual rating
Signicantly lower VHI
scores, phonatory
effort level and voice
disorder severity; voice
perceived as less
breathy and strained;
insignicant changes
in other
measurements,
including MPT,
acoustic analysis, and
laryngeal conguration
Abbreviations: VRQOL, voice-related quality of life; VHI, Voice Handicap Index; FCMs, functional communication measures; ASHA, American Speech-Language-Hearing Association; EMG,
electromyography.
J
o
u
r
n
a
l
o
f
V
o
i
c
e
,
V
o
l
.
-
,
N
o
.
-
,
2
0
1
3
4
subject performed ve speech tasks: 5 seconds of sustained
vowel /a/ phonation, MPT, pitch glide, counting, and oral read-
ings of the Rainbow Passage; each task was repeated for at least
two trials. These voice samples were saved as wav les (at
48 000 Hz of sampling frequency and 16 bits of amplitude res-
olution) on an Olympus LS-10 Linear PCM digital audio re-
corder. The pretreatment baseline was conducted within
1 week before the LSVT, and the posttreatment assessment
was performed approximately 2 weeks after treatment.
Voice treatment
Each subject received a total of sixteen 60-minute sessions of
the LSVT spanning a period of 4 weeks in the care of an
LSVT-certied speech-language pathologist.
41
The rst 30 min-
utes of each treatment session contained drill exercises that
were designed to maximize phonation time and pitch range
and to practice a set of short personally salient sentences (ie,
functional speech) using a shout loud vocal intensity. The
next 30 minutes in each session centered on using high respira-
tory and phonatory efforts (ie, increased vocal intensity) on var-
ious speech tasks, such as oral readings, off-the-cuff questions,
word generation, and conversation. Data collection on phona-
tory function was conducted during each treatment session. In
addition to onsite treatment sessions, each subject was also re-
quired to complete daily home exercise assignments to inte-
grate and reinforce the acquired skills. When the LSVT was
concluded, the subject was expected to continue daily practices
of maintenance exercises at home for retention purposes.
Treatment outcome measurement
Strobolaryngoscopic evaluation of laryngeal congu-
ration. The rst author, a speech-language pathologist with
20 years of experience in voice disorders, assessed laryngeal
conguration from the laryngoscopic images for four parame-
tersgeneral vocal health, severity of vocal fold atrophy and
bowing, glottal closure, and vibratory pattern of the vocal folds.
Status of the glottal closure was determined during the closing
phase of vocal fold adduction; it was assessed based on the size
of glottal gapcomplete closure (ie, no gap), small slit, moder-
ate gap, and large gap.
20
Special attention was also paid to doc-
ument any vocal fold pathology or changes in supraglottic or
transglottic activity that might be indicative of therapy-
induced lesion or maladaptive laryngeal hyperfunction.
Glottal gap measurement. Because actual measurement
of the GGS is unattainable from the laryngoscopic images be-
cause of limitations of current endoscopic technology, the
present study attempted a relative estimation of glottal gap
area by adopting a measurement method described by Omori
et al.
16
One-second video clip was obtained from each strobo-
laryngoscopic examination when the vocal folds were seen to
reach the adductory phase and when both anterior commissure
and the tip of opposing vocal processes were also visible. A
video editing program (Ulead Video Studio 11.0; Corel, Ot-
tawa, CA) was used to process the 1-second video clip into
30 consecutive freeze-frame photographic les. On each still
photographic image, the lines were measured in pixels and
the size of the area was measured in square pixels per line
measurement and area measurement functions featured
in Adobe Creative Suite 6 software (version 13.0.1; Adobe
Systems, Inc., San Jose, CA). In this study, because the dis-
tance between the tips of opposing vocal processes on vocal
fold adduction appeared relatively stable and constant
throughout each laryngoscopic examination, it was considered
a feasible reference for calibration (Figure 1). Among 30 lar-
yngoscopic images in each examination, the image containing
the smallest glottal gap was selected as the benchmark im-
age, and on this image, the intervocal process distance was
used as a calibrating yardstick, and the corresponding GGS
(measured in area pixels) was counted as one basic unit. The
glottal gap areas shown on the remaining 29 images (ie, target
FIGURE 1. Normalized measurement of glottal gap area. Left is the benchmark image, and right is a target image. RVP, tip of the right vocal
process; LVP, tip of the left vocal process; black line, intervocal process distance (in pixels); GG, glottal gap; dashed line area, glottal gap size
(in area pixels).
Fang-Ling Lu, et al Efcacy of LSVT for Presbyphonia 5
images) in each examination were then measured against the
benchmark image and normalized according to the following
formula:
Normalized GGS (in unit) [(IVPD of the target image)/
(IVPD of the benchmark image)]3[(GGS of the target
image)/(GGS of the benchmark image, counted as 1 unit)]
In addition, the occurrence rate of glottal closure was also
roughly estimated by tallying the number of video images
showing complete glottal contact during a vibratory cycle (mea-
sured in percent).
Phonatory function measurement. Three phonatory
function measures, that is, vocal intensity, MPT, and pitch
range, were obtained at pretreatment and posttreatment, as
well as during each of the 16 therapy sessions. The level of vo-
cal intensity was measured with a RadioShack sound pressure
level (SPL) meter at 12 inches of mouth-meter distance when
the subject performed four groups of speech tasksmaximum
phonation of vowel /a/, functional speech, oral readings of sen-
tences or paragraphs, and running speech (eg, off-the-cuff ques-
tions, word generation, or conversation). MPT and pitch range
were measured by using the Real-Time Pitch program (model
5121; KayPENTAX).
Acoustical analyses. The 5-second voice samples of sus-
tained vowel /a/ obtained before and after treatment were ana-
lyzed acoustically using the Multi-Dimensional Voice Program
(model 5105; KayPENTAX). Numerous acoustic parameters
were selected in analysis for their specic properties measuring
the status of vocal fold adduction and ability of sustaining a pe-
riodic and uninterrupted voicing.
52
These acoustic features in-
cluded fundamental frequency (F
0
and F
0
standard deviation),
perturbation (jitter and shimmer), noise evaluation (harmonic-
to-noise ratio and soft phonation index [SPI]), voice break (de-
gree of voice break and the number of voice breaks), and voice
irregularity (degree of voiceless segments and the number of
voiceless segments).
Auditory-perceptual judgment. Voice quality of re-
corded voice samples was assessed per a commonly used
perceptual rating system, that is, the Grade, Roughness,
Breathiness, Asthenia, Strain (GRBAS) scale.
53
Pretreatment
and posttreatment voice samples were rated on ve parame-
ters in the GRBAS scale: Grade (G) indicated the severity
of overall voice abnormality; Roughness (R) represented
voice quality of inharmonic vocal fold vibrations and uctu-
ating fundamental frequency; Breathiness (B) was voice qual-
ity with reference to air leakage through the glottis; Asthenia
(A) was referred to voice quality of weak vocal loudness; and
Strain (S) represented voice quality of tenseness or excess ef-
fort indicative of hyperfunctional voice. Each parameter was
scored on a four-point scale with 0 for normal status, 1 for
mild deviance, 2 for moderate deviance, and 3 for severe
deviance.
Data analysis
Paired samples t tests were performed for pretreatment and
posttreatment comparisons of GGS. Because of potential differ-
ences in the performance effort between therapy sessions and
pretreatment/posttreatment assessments, one-way analysis of
variance (ANOVA) was performed for between-session com-
parisons and paired samples t tests were conducted for
pretreatment-posttreatment comparisons.
RESULTS
Laryngeal conguration
All parameters pertaining to vocal fold status demonstrated dis-
cernible improvements after therapy. Both subjects exhibited re-
duced concavity of the vocal fold edges after treatment. In
response to the treatment, both subjects showed a marked de-
crease of GGS, reducing froma small-to-moderate linear or fusi-
form gap to a minute anterior slit, which at times alternated with
complete or near-complete glottal closure. Positive changes of
vocal fold coloration and mucosal vibration were also noted in re-
lation to therapy. Although both subjects vocal folds were of
mild-to-moderate discoloration and dryness with dilated blood
vessels before treatment, they turned paler in color with reduced
vasodilation after therapy. Vibratory pattern of the mucosal wave
showed positive outcomes after therapy as well, improving from
moderate deviance to normal or near-normal vibratory character-
istics after treatment. It is noteworthy that neither subject ex-
hibited vocal trauma or increased laryngeal hyperfunction after
treatment. Although subject 2 illustrated a mild degree of medial
and anterior-posterior compression of supraglottic structures at
baseline, the degree of supraglottic hyperactive behaviors re-
mained relatively unchanged after treatment.
Glottal gap measurement
Bar charts in Figure 2 shownormalized GGSs of both subjects in
relation to therapy. Treatment-related differences in GGS were
analyzed with paired samples t tests as well. Normalized GGS
(in units) in subject 1 was signicantly reduced from pretreat-
ment (mean, 30.23; range, 9.1470.83; standard error [SE],
2.49) to posttreatment (mean, 5.00; range, 1.0017.06;
SE 1.06) at t(29) 10.50, P < 0.01. In subject 2, a signicant
reduction of the GGS was also observed (t[29] 7.01, P<0.01),
from pretreatment (mean, 42.60; range, 10.7673.08; SE, 2.85)
to posttreatment (mean, 20.18; range, 1.0059.03; SE, 3.20). In
FIGURE 2. Means and standard errors of normalized glottal gap
size of two subjects before and after treatment.
Journal of Voice, Vol. -, No. -, 2013 6
addition, both subjects showed higher frequencies of complete
glottal closure after treatment. Although both subjects had 0%
of glottal closure at baseline, subject 1 reached complete glottal
closures at a rate of 20% in a vibratory cycle (ie, 4 of 20 frames)
and subject 2 attained complete closures approximately 30% in
a vibratory cycle (ie, 8 of 26 frames) after therapy.
Phonatory function measurement
Data of three phonatory function measures (ie, SPL, MPT, pitch
range) were analyzed using two statistical analysis systems,
one-way ANOVA for between-session comparisons and paired
samples t tests for pretreatment-posttreatment comparisons.
Vocal intensity. One-way ANOVA results indicated signi-
cant SPL changes across treatment sessions on all vocal activ-
ities in both subjects (P < 0.05). Rises of SPL were particularly
evident starting the third session of therapy (ie, 1W3) in both
subjects; the gains remained relatively level throughout the re-
maining course of treatment (Figure 3). Results of paired sam-
ples t tests revealed signicantly higher SPL on all speech tasks
after treatment in both subjects (P < 0.05) (Table 2). The sub-
jects SPL measurements rose from an abnormally low level
at baseline to a posttreatment level that has reached the normal
ranges appropriate for subjects respective ages and genders.
Maximum phonation time. Although both subjects
showed signicant differences in MPT across treatment ses-
sions (P < 0.05), only subject 1 exhibited a slow and steady in-
crease over time (Figure 4). Table 2 illustrates that subject 1 had
a signicant gain in MPT (P < 0.05) that reached normal limits
after treatment. In contrast, subject 2 showed remarkably long
MPTat baseline which, unsurprisingly, remained unchanged af-
ter treatment (P 0.80).
Pitch range. Figure 5 shows changes of three pitch range-
related elementsthe highest and lowest attainable pitch
levels and the pitch range (in hertz)of both subjects over
time. Results of ANOVA and t tests (Table 2) indicate signif-
icant increases in the course of treatment in both subjects in
nearly all aspects of pitch range (P < 0.05) except for the low-
est attainable pitch level in subject 2 (P 0.78). Signicant
rises of the highest attainable pitch level and corresponding
increases of the pitch range were observed starting the fth
session of therapy in subject 1 and the rst session of therapy
in subject 2. When the pitch range was converted to semitones
(ST), the pitch range value of subject 1 improved from 20.5
ST to 27.5 ST after treatment, whereas the pretreatment ST
of subject 2 was 16.1 and posttreatment ST was 40.3; the pitch
range of both subjects reached or rose above normal ranges
after treatment.
Acoustical analyses
Table 3 displays the results of acoustical analysis on sustained
vowel phonation along with normative data for compari-
sons.
28,52
Statistical analysis of acoustic data was unattainable
because of limited data points. However, posttreatment
changes were noticed in most acoustic measures, suggesting
increased glottal competence and phonatory control after
treatment. Positive changes were particularly evident in
subject 1 whose acoustic measures in nearly all categories
were brought to within or close to normal ranges after
treatment despite markedly deviant features at baseline. On
the other hand, subject 2 exhibited only mild deviance on
some acoustic features that showed little changes after
treatment with the exception of noise measures. Values of
noise measures (ie, harmonic-to-noise ratio and SPI) in both
subjects were lowered after treatment, which is of particular in-
terest to this study because reduced SPI value may be an indi-
cation of stronger vocal fold adduction.
FIGURE 3. Mean of SPL (dB) of two subjects at pretreatment, dur-
ing 16 therapy sessions, and at 2-week posttreatment. SPL data were
obtained for four speech tasks. Sixteen therapy sessions were denoted
as Pre (pretreatment), 1W1 (rst session in the rst week), 1W2 (sec-
ond session in the rst week), 2-wk Post (2 weeks posttreatment), and
so on. Pretreatment and posttreatment data points were not connected
to the trend line of the treatment session data because of different per-
formance efforts. SPL measures on pretreatment and posttreatment as-
sessments were obtained when subjects performed at a habitual level of
pitch and loudness, whereas the SPL measures during treatment ses-
sions were collected when subjects practiced loudness drill exercises
using the think loud, shout loud strategy. Age-matched normative
values of habitual speaking intensity for males
54
are 72.4 4.4 dB
and for females
55
are 67.42 2.93 dB.
Fang-Ling Lu, et al Efcacy of LSVT for Presbyphonia 7
Auditory-perceptual judgments
The pretreatment voice quality of subject 1 was perceived as
hoarse, breathy, weak and of shortened phrasing, which was
rated on the four-point GRBAS scale as Grade (2), Roughness
(1), Breathiness (2), Asthenia (2), and Strain (0), with 0 being
normal to 3 being extremely deviant. Her voice quality after
treatment was perceived to be relatively normal with just a trace
of breathiness and was rated as G
1
R
0
B
1
A
0
S
0
. The voice quality
of subject 2 before therapy was characterized as hoarse,
breathy, weak, and slightly shaky, which was rated as
G
2
R
2
B
2
A
2
S
0
. His posttreatment voice quality was perceived
as mildly hoarse and shaky and was rated as G
1
R
1
B
1
A
0
S
0
.
DISCUSSION
The present study supported efcacy of the LSVT for rehabili-
tating hypofunctional voice associated with age-related vocal
fold atrophy and bowing. In this study, two subjects demon-
strated evident post-LSVT improvement in every aspect of vo-
cal function, including glottal closure (ie, GGS and glottal
closure rate), coloration and mucosal vibration of the vocal
folds, phonatory function, acoustic features, and perceptual
voice quality. In subject 1, nearly all measures reached norma-
tive ranges after treatment despite much pervasive glottal gap
and deviant voice features at baseline. Session-by-session
tracking of the phonatory function in particular showed notable
improvement as early as the second week of the treatment in
both subjects. The results of this study generally corroborate
with the ndings reported by Ramig et al,
3
who too used the
LSVT to treat three aged speakers, despite some distinct
measurement differences between two studies. Ramig et al
3
documented greater subglottic air pressure and increased elec-
tromyographic activity in the thyroarytenoid muscle after ther-
apy in all subjects, presumed to reect stronger glottal closure
related to treatment, although only one subject showed im-
proved vocal fold adduction per videostroboscopy. Another
study by LaGorio et al
47
revealed positive effects on the glottal
closure and the phonatory function of speakers with vocal fold
bowing when a combined behavioral therapy (ie, NMES paired
with 14-step vocal exercises) was used. Taken together, cumu-
lative evidence fromthree studies supports the notion that inten-
sive exercise-based programs are highly effective in treating
glottal incompetence related to presbyphonia.
It is thought that a weakened thyroarytenoid muscle is the
culprit behind vocal fold bowing.
17,18,56
For that reason, any
voice therapy, such as the LSVT, that uses rigorous vocal
exercises to increase laryngeal muscle contraction and
coordination would be expected to lessen vocal fold bowing
TABLE 2.
Means and SDs of Phonatory Function Measurement at Pretreatment and Posttreatment Assessments and Results of
Paired Samples t Tests
Measures
Pretreatment Posttreatment
Statistical Results
(Two Tailed)
M (SD) Range M (SD) Range t Values P Values
Subject 1
Vocal intensity (dB)
/a/ phonation 65.17 (7.36) 5170 87.02 (4.43) 7097 5.82 <0.05*
Functional speech 65.61 (3.79) 5370 68.12 (3.66) 6279 5.92 <0.05*
Reading 64.92 (3.49) 5270 69.71 (2.97) 6373 4.39 <0.05*
Running speech 60.29 (3.95) 5468 68.12 (3.66) 6279 6.67 <0.05*
MPT (s) 8.19 (2.38) 5.5010.04 12.83 (0.98) 1214 5.21 <0.05*
Pitch range (Hz)
Highest pitch 342.45 (28.10) 322.58396.83 1105.27 (78.16) 1050.001160.53 21.55 <0.05*
Lowest pitch 103.20 (28.73) 81.83135.86 182.88 (14.16) 160.36209.00 19.22 <0.05*
Range 257.38 (65.13) 186.72315.00 712.76 (350.67) 316.01981.26 24.13 <0.05*
Subject 2
Vocal intensity (dB)
/a/ phonation 75.15 (3.32) 6780 84.73 (1.57) 8188 18.32 <0.05*
Functional speech 64.16 (2.70) 6069 71.97 (1.76) 6977 12.99 <0.05*
Reading 65.10 (3.10) 6071 70.59 (2.54) 6677 7.42 <0.05*
Running speech 58.96 (4.07) 5068 67.21 (4.08) 6172 4.77 <0.05*
MPT (s) 27.50 (10.79) 1237 23.67 (5.51) 2030 0.28 0.80
Pitch range (Hz)
Highest pitch 389.81 (10.63) 378.79400.00 920.32 (9.72) 909.09925.93 61.75 <0.05*
Lowest pitch 83.86 (12.88) 72.8998.04 89.73 (28.30) 70.72122.25 0.31 0.78
Range 305.95 (18.54) 292.59327.11 830.59 (25.84) 803.68855.21 51.55 <0.05*
Abbreviation: SDs, standard deviations.
* Analysis of variance test: p < 0.05.
Journal of Voice, Vol. -, No. -, 2013 8
and thus increase glottal closure. The LSVT program
specically focuses on vocal activities including vocal
intensity and pitch, which are two vocal parameters that
predictably demand greater lung pressure and glottal
resistance.
57,58
Consequently, the individuals would acquire
greater respiratory drive and stronger contraction of laryngeal
muscles, such as thyroarytenoids and cricothyroids, when
they undergo the LSVT training program.
3,30,5962
Both
subjects in the present study demonstrated decreased vocal
fold bowing and reduced glottal gap after treatment. In fact,
normalized GGS decreased 83% (from 30 to 5 units) in
subject 1 and 84% (from 43 to 7 units) in subject 2 when the
therapy was concluded, and the glottal closure rate per
vibratory cycle rose from zero to 20% in subject 1 and from
0% to 30% in subject 2 after treatment; normally, each glottal
cycle has an opening/closing phase at 67% and a closed
phase at 33%.
6368
However, both glottal closure measures
obtained in the study should be viewed with great caution and
not to be compared with normative data that were collected
with more sophisticated technology. This is because of the
fact that one of several limitations of videostroboscopy
pertains to its low sampling rate, about 3035 frames per
second, which is too low to capture individual cycles of vocal
fold vibration for precise measurement of glottal closure.
69,70
Nonetheless, with the stringent measurement protocol applied
in this study, the glottal closure measures obtained in both
subjects provide valid within-subject comparisons to determine
the treatment effect. Our strobolaryngoscopic ndings also in-
dicated positive changes pertaining to mucosal appearance
and vibration of the vocal folds after the LSVT. After treatment,
discoloration, dryness, and hyperemia observed at baseline no-
tably diminished, and the mucosal vibration approached a near-
normal pattern in terms of amplitude and periodicity. Although
subjects in the present study did not develop any vocal fold le-
sion or an increase of hyperfunctional laryngeal behavior after
the LSVT, LaGorio et al
47
in fact reported reduced supraglottic
compression in their subjects with vocal fold bowing after
a combined NMES and 14-step vocal exercises treatment. It
FIGURE 4. Means of MPT of two subjects at pretreatment, during
16 therapy sessions, and at 2-week posttreatment. Sixteen therapy ses-
sions were denoted as Pre (pretreatment), 1W1 (rst session in the rst
week), 1W2 (second session in the rst week), 2-wk Post (2 weeks
posttreatment), and so on. Pretreatment and posttreatment data points
were not connected to the trend line of the treatment session data be-
cause of different performance efforts. MPT measures on pretreatment
and posttreatment assessments were obtained when subjects performed
at a habitual level of pitch and loudness, whereas the MPT measures
during treatment sessions were collected when subjects practiced
MPT drill exercises potentially under the inuence of loud speaking
behavior. Age-matched normative values of MPT (in seconds) for
males
25
are 18.0 6.0 and for females
55
are 20.57 8.51.
FIGURE 5. Means of the highest and lowest pitch levels of two sub-
jects at pretreatment, during 16 therapy sessions, and at 2-week post-
treatment. Sixteen therapy sessions were denoted as Pre
(pretreatment), 1W1 (rst session in the rst week), 1W2 (second ses-
sion in the rst week), 2-wk Post (2 weeks posttreatment), and so on.
Note that subject 2 had missing data for 7 of 18 recording sessions
(1W3, 1W4, 2W4, 3W2, 3W3, 3W4, 4W4) because of lost records.
The lightly shaded marker on each vertical line represents the highest
attainable pitch, and the black marker represents the lowest attainable
pitch. Pretreatment and posttreatment data points were not connected
to the trend line of the treatment session data because of different per-
formance efforts. Pitch glide measures on pretreatment and posttreat-
ment assessments were obtained when subjects performed at
a habitual loudness level, whereas the pitch glide measures during
treatment sessions were collected when subjects practiced pitch glide
drill exercises potentially under the inuence of loud speaking
behavior.
Fang-Ling Lu, et al Efcacy of LSVT for Presbyphonia 9
is thought that a reduced amount of supraglottic hyperactivity
may be associated with improvement of glottal closure, indica-
tive of positive effects from voice intervention on laryngeal
function.
71
The evidence of improved glottal closure in both subjects
seems to be congruent with the changes in numerous acoustic
parameters, such as SPI or voice break, that are supposedly in-
dicative of rmer vocal fold adduction and improved ability to
sustain a steady and uninterrupted voice. Unfortunately, the
data points collected in the present study were insufcient for
an in-depth acoustical analysis and could only render us a tenta-
tive conclusion regarding the effect of the LSVT on acoustic
voice features associated with presbyphonia. However, our re-
sults indicated LSVT effectiveness on vocal fold adduction
and vocal efciency, as evidenced by improved phonatory func-
tion and perceptual voice quality. In addition to obvious
improvements in vocal intensity, MPT, and pitch range, the
GRBAS rating also demonstrated improvement in both subjects
after treatment. Extensive research evidence reported in the
literature supports the efcacy of the LSVTfor treating vocal in-
competence in speakers of neurogenic communication disor-
ders,
61,72,73
and the regimen manifests the same effects in both
individuals with presbyphonia in this study. Cumulative
evidence thus far afrms that intensive behavioral voice
therapy alone, namely the LSVT program, could be a cost-
effective approach for rehabilitating dysphonia related to
presbylaryngis. In spite of unequivocal therapeutic benets of
electrical muscular stimulation for strengthening limb mus-
cles,
7476
the benet of using NMES alone for treating glottal
incompetence remains debatable. A closer examination of
several treatment outcome studies indicates that NMES may
enhance vocal function improvement if applied in conjunction
with behavioral therapy such as effortful swallowing
technique,
77
14-step vocal exercises,
47
or unspecied vocal ex-
ercise
78
per daily treatment schedule, but there is no conclusive
evidence conrming the signicance of NMES alone in voice
therapy.
Despite the promising treatment outcomes of the LSVT for
speech and voice dysfunction of various etiologies, the main
challenge of implementing the program in clinical settings
lies in the accessibility issue. The demand of delivering the
treatment in daily in-person treatment sessions over a 4-
week period is unfeasible for clients who have mobility and
geographic barriers and for clinicians who have heavy work-
loads. Fortunately, the continuing efforts for developing
more and varied ways of service delivery offer potential solu-
tions to meeting the needs of both patients and clinicians and
to reaching a greater number of clients who can benet from
the treatment. The LSVT administered with an alternative
treatment schedule, that is, 16 treatment sessions delivered
over 2 months instead of 1 month, appeared equally effective
as the original protocol.
79
The use of online delivery of the
LSVT via videoconferencing was also proven to be clinically
valid and reliable for treating the PD patients.
7483
Furthermore, a recently developed assistive treatment system
(ie, LSVT Companion), which allows the client to receive
half of the LSVT sessions at home, also achieved similar
treatment gains as the standard LSVT in a study by Halpern
et al.
84
The recent exploration of innovative technology
indeed offers alternative means for delivering the LSVT in
TABLE 3.
Means of Pretreatment and Posttreatment Acoustic Measurements
Acoustic Measurements
Subject 1 Subject 2 Age-Matched Norms*
Pre-LSVT Post-LSVT Pre-LSVT Post-LSVT Norms of All Ages
Fundamental frequency
F
0
(Hz) 229.10 248.43 165.11 170.06 Female* 183.4 31.9
28
Male* 144.9 34.6
28
F
0
standard deviation (Hz) 14.49 3.81 4.75 4.84 Female* 5.2 3.2
28
Male* 10.3 8.1
28
Perturbation
Jitter (%) 3.12 0.51 0.94 0.73 Female* 1.15 0.82
28
Male* 1.4 1.11
28
Shimmer (dB) 0.81 0.51 0.12 0.12 Female* 0.3 0.15
28
Male* 0.56 0.39
28
Noise evaluation
Harmonic-to-noise ratio 5.00 8.85 6.06 7.09 Female* 9.57 5.31
28
Male* 3.61 5.34
28
SPI 23.75 3.03 9.79 4.54 Female 7.53 4.13
52
Male 6.77 3.78
52
Voice break
Degree of voice break (%) 9.90 0 0.05 0 Female/male 0.2 0.1
52
No. of voice breaks 6 0 1 0 Female/male 0.2 0.1
52
Voice irregularity
Degree of voiceless (%) 25.53 1.13 1.37 2.54 Female/male 0.2 0.1
52
No. of unvoiced segments 33 5 15 14 Female/male 0.2 0.1
52
Journal of Voice, Vol. -, No. -, 2013 10
a cost-effective and feasible manner, which can also be seen as
a motivational factor for the individuals who can benet from
voice therapy to seek treatment.
It is recognized that the present study has several limitations.
With only two subjects, caution must be taken when generaliz-
ing the results of this study to a broader treatment-seeking pop-
ulation of presbyphonia. We recommend that future studies
include larger group comparisons (control group or NMES
group) with inferential statistics and include an addition of
quality of life measures, such as voice-related quality of life
or Voice Handicap Index. We also recommend that future stud-
ies include visual and auditory evaluations of voice performed
by an examiner blind to treatment conditions (before and after)
or subject group. Given technological limitations of videostro-
boscopy that do not allowdetailed evaluation of the vocal folds
dynamic behavior, future studies should consider using more
sophisticated technology or additional analyses, for example,
videokymography, electromyography, electroglottography, or
transglottal airow measure, to offer precise measurement of
vocal fold adduction or glottal closure during vocal fold vibra-
tion. Furthermore, the present study did not conduct follow-up
assessments beyond 2 weeks after treatment, thus it remains un-
answered if positive gains from the LSVT could be sustained in
speakers with presbyphonia months or years after treatment.
However, it is a reasonable assumption that the LSVT has equi-
valent long-termeffect on vocal function related to presbyphonia
as it does onPD.
61,79,85
Despite the aforementioned shortcomings
of the study, the results clearly show the potential of the LSVT
regimen in treating glottal incompetence and hypofunctional
phonation.
CONCLUSION
The results of our investigation showsignicant post-LSVTim-
provement on glottal closure, phonatory function, acoustic
voice features, and perceptual voice quality in two subjects
with presbyphonia. This study provides objective and subjec-
tive outcome measures in support of intensive exercise-based
behavioral therapy as an effective therapeutic approach for re-
habilitating aging vocal folds. In the present study, methodical
data collection and analysis were conducted for pretreatment
and posttreatment comparisons as well as the progress of pho-
natory function in the course of therapy.
Future investigation of the LSVT using a larger number of
elderly treatment-seeking and normal control subjects is war-
ranted. Advanced instrumental measurements should also be
used to investigate underlying changes of respiratory and
phonatory functions in response to the LSVT. Additionally,
future studies should include short-term and long-term fol-
low-ups to determine sustainability of treatment-related im-
provements associated with presbyphonia, even with speakers
with recurrent laryngeal nerve paralysis who also exhibit
hypofunctional voice. Finally, concurrent application of
NMES during the LSVT has merits for future investigation to
determine if adjunctive electrical muscular stimulation may
expedite treatment progress or bolster long-term sustainability
of improvements.
Acknowledgments
Equipment funding for this project was provided by the Re-
search Infrastructure Grant from the University of North Texas.
The authors thank Martha Norwood and Tiffanie Klement for
their assistance in data collection.
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