Effects of Interdisciplinary Choral Singing Therapy on the Voice and Swallowing Function of Individuals with Parkinson’S...

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Title:
Effects of Interdisciplinary Choral Singing Therapy on the Voice and Swallowing Function of Individuals with Parkinson’S Disease
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english
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Funderburke, Sarah K
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Master's ( M.A.)
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University of Florida
Degree Disciplines:
Communication Sciences and Disorders, Speech, Language and Hearing Sciences
Committee Chair:
Sapienza, Christine M
Committee Members:
Wingate, Judith M

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parkinson -- singing -- swallowing -- therapy -- voice
Speech, Language and Hearing Sciences -- Dissertations, Academic -- UF
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Communication Sciences and Disorders thesis, M.A.
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theses   ( marcgt )
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Abstract:
Degenerative changes frequently occur to voice and swallowing function for many individuals with Parkinson’s disease (PD) (Hoehn & Yahr, 1967; Sapienza & Hoffman Ruddy, 2009). Swallowing dysfunction in particular increases the risk of aspiration and pneumonia, a strong predictor of death (Fernandez & Lapane, 2002; Hoehn &Yahr, 1967). A small number of studies indicate that choral singing treatments are beneficial for improving vocal function in those with PD (di Bennedetto et al., 2009; Haneishi, 2002). More research is needed to determine the effectiveness of choral singing treatments in treating voice problems in individuals with PD. No studies have discussed potential benefits of choral singing treatment on swallowing function. The current study investigated an interdisciplinary approach to voice and swallowing treatment in those with PD that combined both music and voice therapy paradigms. Participants were three adult males between the ages of 67 and 85 years of age (H&Y < 3.0; MMSE>24). This treatment involved an eight-week course of weekly one-hour combined modality sessions, implementing vocal, respiration, and articulation warm-up exercises, and choral singing of familiar songs. Intervention sessions were supplemented with home practice, consisting of a CD of vocal function exercises and intervention session songs. Pre and post-test measures of maximal phonation tasks, maximum sound pressure level, maximum frequency range, maximum expiratory and inspiratory pressure, physiologic measures of swallow function, and quality of life related to voice and swallowing were compared to determine effects of the treatment. Results indicate that after completing interdisciplinary choral singing therapy (ICST), all participants increased SPL, MEP, and MPT. Results for MFR and MIP indicated some reductions in those measures with treatment. Results for swallowing function revealed increases in the angle of elevation and magnitude of hyoid bone displacement during three sequential swallows each of 10 ml thin liquid and pudding thick barium. The results of this study suggest that ICST can result in positive voice and swallowing outcomes for those with PD. This motivating and socially engaging therapy option may be used alone or in conjunction with more established therapy programs.
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In the series University of Florida Digital Collections.
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Includes vita.
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by Sarah K Funderburke.
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Thesis (M.A.)--University of Florida, 2012.
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Adviser: Sapienza, Christine M.
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RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2013-05-31

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1 EFFECTS OF INTERDISC IPLINARY CHORAL SING ING THERAPY ON THE VOICE AND SWALLOWING FUNCT ION OF INDIVIDUALS W ASE By SARAH KATHERINE FUNDERBURKE A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR TH E DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2012

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2 2012 Sarah Katherine Funderburke

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3 To my family

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4 ACKNOWLEDGMENTS This thesis would not have been written without the incredible support and direct ion given by my committee chair and member Dr. Christine Sapienza and Dr. Judith Wingate. Throughout every step of the research and writing process they have made themselves available to answer abounding questions, to address all concerns, and to instill in me enthusiasm for research and its clinical applications I give special thanks to Dr. Judith W ingate for leading and supervising the research team during data collection and analysis. I would also like to thank Dr. Lori Altmann for her patience in teaching me about proper data collection procedures and re search design and always driving me to be the best I can be. I give many thanks to Dr. Elizabeth Stegemoller for her role as principal investigator of this project, in addition to her constant encouragement, attention to my multitude of questions, and hel pful advice about writing and overall research. In addition, I thank Ms. Lisa Kopf for her support, advice, and collaboration on recruitment, data collection, data analysis, background researc h, and countle ss other tasks. I give special thanks to Dr. Mi chelle Troche for her support of the project, clinical supervision and advice regarding the clinical care of patients with sease. Al so, I send thanks to my friends and family for cheering me on and always believing that I c ould do great things Finally, I would like to thank th e Speech and Hearing Center of Shands hospital for the use of the facility the UF Center for Mo vement Disorders and Neurorestoration for aiding in recruitment, and the department of Speech, Language, and Hearing Sciences at UF for securing the needed funding for this pilot study.

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5 TABLE OF CONTE NTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 Voice Disorders ................................ ................................ ................................ ...... 11 Voice Disorders in Persons with PD ................................ ................................ 11 Current Voice Research ................................ ................................ ................... 14 Established Voice Therapy ................................ ................................ ............... 15 Dysphagia ................................ ................................ ................................ ............... 16 Dysphagia in Perso ns with PD ................................ ................................ ......... 16 Current Dysphagia Research ................................ ................................ ........... 18 Established Dysphagia Treatments ................................ ................................ .. 20 Music Therapy and PD ................................ ................................ ........................... 22 Singing and Voice Treatment in PD ................................ ................................ ........ 24 2 METHODS ................................ ................................ ................................ .............. 27 Participants ................................ ................................ ................................ ............. 27 Dropouts and Adherence ................................ ................................ ........................ 27 Data C ollection Pre and Post Intervention ................................ ............................ 28 Videoflouroscopic Procedure Pre and Post Intervention ................................ ....... 29 Singing Therapy Intervention Procedures ................................ ............................... 30 Vocal Exercises ................................ ................................ ................................ ...... 30 Choral Singi ng ................................ ................................ ................................ ........ 32 Data Analysis ................................ ................................ ................................ .......... 33 3 RESULTS ................................ ................................ ................................ ............... 37 Voice Measures ................................ ................................ ................................ ...... 37 MPT ................................ ................................ ................................ .................. 37 MFR ................................ ................................ ................................ ................. 38 SP L ................................ ................................ ................................ .................. 39 MEP ................................ ................................ ................................ ................. 40 MIP ................................ ................................ ................................ ................... 41 V RQOL ................................ ................................ ................................ ............ 42 Swallowing Measures ................................ ................................ ............................. 43

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6 Hyoid Bone Displacement Measures ................................ ............................... 44 Hyoid bone angle of elevation ................................ ................................ .... 44 Hyoid bone magnitude displacement ................................ ......................... 45 P A Score ................................ ................................ ................................ ......... 47 SWAL QOL ................................ ................................ ................................ ...... 48 4 DISCUSSION ................................ ................................ ................................ ......... 49 Voice Outcomes ................................ ................................ ................................ ..... 49 Swallowing Outcomes ................................ ................................ ............................. 53 5 CONCLUSIONS AND FUTURE RESEARCH ................................ ......................... 58 APPENDIX A VOICE MEASURE AND HYOID DISPLACEMENT CHANGE SCORE TAB LES .... 60 B WEEKLY INTERVENTION SPL FIGURES ................................ ............................. 63 LIST OF REFERENCES ................................ ................................ ............................... 64 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 72

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7 LIST OF TABLES Table page 2 1 Inclusion and exclusion criteria ................................ ................................ ........... 27 2 2 Penetration Aspiration Scale ................................ ................................ .............. 34 3 1 Penetration Aspiration Scale scores pre and post intervention for thin liquid barium swallows ................................ ................................ ................................ 48 A 1 Maximum phonation time for /a/ (in seconds) from pre to post treatment .......... 60 A 2 Maximum phonation time of /i/ (in seconds) from pre to post treatment ............. 60 A 3 Maximum frequency range (in semitones) from pre to post treatment ............... 60 A 4 Maximum sound pressure level (in dB SPL) ................................ ....................... 60 A 5 Maximum expiratory pressure (in cm H 2 0) from pre to post treatment ............... 60 A 6 Maximum inspiratory pressure (in cm H 2 0) from pre to post treatment .............. 60 A 7 V RQOL scores pre and post ICST ................................ ................................ .... 61 A 8 Participant 2 average angle of elevation (in degrees) for thin liquid ................... 61 A 9 Participant 2 average angle of elevation (in d egrees) for pudding thick liquid .... 61 A 10 Participant 3 average thin liquid angle of elevation (in degrees) ........................ 61 A 11 Participant 3 average pudding thick angle of elevation (in degrees) ................... 61 A 12 Participant 2 average thin liquid magnitude displacement (in millimeters) .......... 61 A 13 Participant 2 average pudding thick magnitude displacement (in millimeters) .... 61 A 14 Participant 3 magnitude displacement (in millimeters) for thin liquid barium swallows ................................ ................................ ................................ ............. 62 A 15 Participant 3 magnitude displacement (in millimeters) for pudding thick barium swallows ................................ ................................ ................................ 62

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8 LIST OF FIGURES Figure page 2 2 Example of measurements the Mainrand MATLAB routi ne makes during task analysis. ................................ ................................ ................................ ............. 35 3 1 Maximum phonation time of /a/ (in seconds) pre to post treatment ................... 37 3 2 Maximum phonation time of /i/ (in seconds) from pre to post treatment ............ 38 3 3 Indivi dual MFR (in semitones) from pre to post treatment ................................ .. 39 3 4 Individual SPL (in dB SPL) from pre to post treatment ................................ ....... 40 3 5 Individual MEP (in cm H 2 0) from pre to post treatment ................................ ...... 41 3 6 Individual MIP (in cm H 2 0) from pre to post treatment ................................ ........ 42 3 7 Individual V RQOL scores from pre to post treatment ................................ ........ 43 3 8 Participant 2* angle of elevation (in degrees) while swallowing thin l iquid and pudding thick barium consistencies ................................ ................................ .... 44 3 9 Participant 3* angle of elevation (in degrees) for thin and thick liquid swall ows 45 3 10 Participant 2* magnitude hyoid displacement (in millimeters) for thin and thick liquid swallows ................................ ................................ ................................ .... 46 3 11 Participant 3* magnitude hyoid displacement (in millimeters) for thin and pudding thick liquid swallows ................................ ................................ .............. 47 3 12 SWAL QOL overall score pre and post treatment ................................ .............. 48 B 1 Weekly individual SPL during Messa di Voce exercises ................................ ..... 63 B 2 Weekly individual SPL during choral singing ................................ ...................... 63

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9 Abstract of Thesis Presented to the Graduate School of the University of Fl orida in Partial Fulfillment of the Requirements for the Master of Arts Degree EFFECTS OF INTERDISC IPLINARY CHORAL SING ING THERAPY ON THE VOICE AND SWALLOWING FUNCT ION OF INDIVIDUALS W ASE By Sarah Katherine Funderburke May 2012 Chair: Christine Sapienza Major: Communication Sciences and Disorders Degenerative changes frequently occur to voice and swallowing function for many ( Hoehn & Yahr, 1967 ; Sapienza & Hoffman Ruddy, 2009 ) Swallowing dysfunction in particular increases the risk of aspiration and pneumonia a strong predictor of death (Fernandez & Lapane, 2002 ; Hoehn &Yahr, 1967 ) A small number of studies indicate that choral singing treatments are beneficial for i mproving vocal function in those with PD ( D i Bennedetto et al., 2009; Haneishi, 2002) More research is needed to determine the effectiveness of choral singing treatments in treating voice proble ms in individuals with PD No studies have discussed potential benefits of choral singing treatment on swallowing function The current study investigated an inter disciplinary approach to voice an d swallowing treatment in those with PD that combined both music and voice therapy paradigms Participants were three adult males between the ages of 67 and 85 years of age ( H&Y < 3.0 ; MMSE > 24 ) This treatment involved an eight week course of weekly one hour combin ed modality sessions, implementing vocal, respiration, and articulation warm up exercises, and choral singing of familiar songs Intervention sessions were

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10 supplemented with home practice consisting of a CD of vocal function exercises and intervention session songs Pre and post test meas ures of maximal phonation tasks, maximum sound pressure level, maximum frequency range, maximum expiratory and inspiratory pressure, physiologic measures of swallow function and quality of life related to voice and swallowing were compared to determine e f fects of the treatment. Results indicate that after completing interdisciplina ry choral singing therapy (ICST) all participants increased SPL MEP and MPT Results for MFR and MIP indicated some reductions in those measures with treatment Results fo r swallowing function revealed increases in the angle of elevation and magnitude of hyoid bone displacement during three sequentia l swallows each of 10 ml thin liquid and pudding thick barium The results of this study suggest that ICST can result in posit ive voice and swallowing outcomes for those with PD This motivat ing and socially engaging therapy option may be used alone or in conjunction with more established therapy programs

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11 CHAPTER 1 INTRODUCTION pyramidal system of the brain, primarily the substantia nigra in the basal ganglia (Brissaud, 1925; Greenfield and Bosanquet, 1953). causes disordered movements of the body, most commonly hypokinesia as first described by James Parkinson in 1817 These disordered movements are a result of dopamine deplet ion within the striatum of the brain (Bertler & Rosengred, 1959). affects approximately 50 per 100,000 people above the age of 50 years causing devastating changes to the body and severely impacting quality of life (Duffy, 2005 ) The etiology of PD is unknown, but there is evidence of both environmental and genetic contributing factors ( Moore, West, Dawson, & Dawson, 2005) According to Duffy (2005), the primary characteristics of parkin sonism are tremor at rest, rigidit y, bradykinesia, or reduction in muscle speed of activation, and loss of postural reflexes. A study by Hoehn an d Yahr (1967) indicated that initial symptoms most frequently include tremor, gait disturbance, slowness, stiffness and muscle pain, loss in handwr iting dexterity, drooling, facial masking or facial hypomimia as well as dysphagia and speech /voice difficulties most often in the form of hypokinetic dysarthria. Voice Disorders Voice Disorders in Persons w ith PD Approximately 89% of people worldwide with idiopathic PD have disordered communication (Fox et al 2006) and approximately 90% of individuals with idiopathic PD develop hypokinetic dysarthria ( Muller, et al., 1971; Du ffy, 2005 ) James Parkinson

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12 (1817) describ ed symptoms of hypokinetic dysarthria when he described a patient exhibited reduced loudness and imprecise articulation to the point that caregivers could not understa nd. Hypokinetic dysarthria is a motor speech disorder characterized by imprecise articulation, monotone prosody, increased or decreased rate of speech, and /or ins ufficient respiratory drive (Darl e y, Aronson, & Brown, 1969 ) The voice disorder within the defined hypokinet ic dysarthria is characterized as hypophonia, or pathologically reduced loudness. It is also characterized by hoarse ness / rough vocal quality, lowering or raising of average speaking pitch and reduced pitch range (Duffy,2005 ; Sapienza & H offman Ruddy, 2009; Spielman et al., 2007 ; Narayana et al., 2010 ) Individuals with PD can also experience vocal tremor. These changes to the voice A study by Holmes, Oates, Phyland, and Hughes (2000) that examined 30 patients with early stage PD, 30 patients wi th late stage PD, and 30 healthy controls, found that men with PD showed increased jitter and harshness, and a high speaking fundamental frequency that did not seem to degenerate w ith the progression of the disease. This study found that women with PD have reduced fundamental frequen cy variability that did not seem to degenerate with the progression of PD In both men and women, l oudness levels, breathy vocal quality monopitch an d monoloudness, and maximum pitch range worsened in the later stages of PD. Additionally, vocal tremor was found only in later stage PD (Holmes, Oates et al. 2000) These findings were similar to another study by Gamboa and associates (1997 ), which measured the acoustic features of the voice in participants with PD compared to healthy control subjects. The researchers disc overed increased jitter and lower harmonic/noise ratio

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13 during sustained vowel phonation of /a/ and lower frequency and intensity variability during connected speech of a sentence in those with PD. Also, a higher frequency of monopitch, voice arrests, and struggle were noted in those with PD compared to healthy controls. Another study by Perez, Ramig, Smith, and D romey (1996) determined that 55% of 22 individuals with idiopathic PD displayed predominantly vertical laryngeal tremor and phase asymmetry during sustained phonation while undergoing endoscopy and stroboscopy This study also found that in the majority of the patients with idiopathic PD, vocal fold amplitude and mucosal wave were normal. Studies by Baker and associates (1998) and Luschei a nd colleagues (1999) indicated decreases in thyroarytenoid (TA) motor un it activity and firing rate possibly adding to the decreased vocal loudness produced within the PD population, and suggesting that laryngeal dysfunction may be related to a sensory ga ting issue versus muscular rigidity (Ramig, Fox, Sapir, 2 0 04 ). Respiratory function also decline s in individuals with PD (Ramig, Fox, & Sapir, 2004) contributing to the symptoms of reduced loudness and reduced sustained phonation duration. Phonation durat ion and intensity rely in part to the degree of respiratory pressures that are produced by an individual ( Draper, Ladeford, & Whitteridge, 1959; Finnegan, Luschei, & Hoffman, 2000). Maximum voluntary ventilation (MVV), forced vital capacity (FVC), m aximum expiratory pressure (MEP), and m aximum inspiratory pressure (MIP) were all significantly reduced when compared to healthy control subjects in a study by Sathyaprabha and colleagues ( 2005). Improvement on pulmonary function test ing measures was found when participants

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14 state with levodopa Seccombe and associates (2011) also found that although exhibiting normal lung volumes and flow, the majority of patients with mild moderate PD demonstrated MEP s and MIP s below the lower limit of norms (Black & Hyatt, 1969 ) and abnormal ventilatory control. Current Voice Research R esearch has been conducted investigating individual voice therapy and group voice therapy to improve hypophoni a, respiratory functioning, speech intelligibility and other vo cal deficits of patients with PD. Individual therapy targeting speech and vocal function, completed before 1990, yielded limited generalization and magnitude of change (Searl et al., 2011). Some case control studies did reveal positive results, however. One study by Robertson and Thomson (1984) revealed that intense speech therapy of 40 hours over 2 weeks yielded significant improvement in articulation and phonation. Another case control study by Johnson and Pring (1990) targeted maximum intensity and f undamental frequency in 10, 1 hour sessions over 4 weeks with the result of improved pitch, vocal intensity, and decreased dysarthria scores. These studies showed that with more intensive speech therapy, improvements in speech and voice of patients with P D do occur. Outcomes associated with group voice therapy are far less studied than outcomes associated with individual voice therapy. Recently, g roup voice therapy has been shown to increase voice related quality of life (V RQOL) scores and vocal symptom s scores in 12 adult teachers with hyperfunctional dysphonia, with the treatment gain lasting 6 months post treatment (Law et al., 2012). A study by Searl and colleagues (2011) indicated that group voice therapy for individuals with PD is a feasible thera py option. This study collected positive participant and clinician feedback about an

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15 8 week voice group utilizing modified LSVT tasks. Additionally, positive changes in loudness, pitch range, and Voice Handicap Index (VHI) were demonstrated for 15 adult s ubjects, with a mean age of 70.4 +/ 11.1. Established Voice Thera py Treat ment of disordered voice in those with PD has been historically difficult due to the variability of speech and vocal performance from day to day, at different times of the medicati on cycle, and d ue to interactions with age, sex years since onset, and other variables ( Denny & Behari, 1999 ) The most efficacious program to date is the Lee Si lverman Voice Treatment (LSVT ) program first reported by Ramig, Countryman, Thompson, and Horii (1995 ) It is the only speech/voice treatment for those with PD that is supported by Level I efficacy data and not only has been shown to increase vocal loudness levels, but also has evidence of changes in vocal quality, speech inte lligibility, and articulation ( Ramig e t al., 2001; Spielman et al., 2007) Specifically, Spielman and colleagues (2 007) reported that LSVT i mproved vocal loudness by 8 dB SPL after pat ients received therapy 4 times per week for 4 weeks and in an extended version (LSVT X), in which pat ients received therapy 2 tim es per week for 8 weeks. For the LSVT X extended program, these increases were maintained after 6 months at 7.2 dB SPL. Further res earch investigations have shown that high effort, intensive, amplitude training within the LSVT program led to improved la ryngeal and respiratory measures, but also showed distributed effects to the speech intelligibility swallowing, and facial expression ( El Sharkawi, et al., 2002; Spielman, Borod, & Ramig, 2003 ) A study by Fox and colleagues (2006), suggests that this ma orofacial muscles to the neurologic systems of respiratory and laryngeal control in normal human research

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16 Dysphagia Dysphagia in Persons w ith PD The act of swallowing is a mixed voluntary and autonomic controlled event, which occurs in three major stages: oral, pharyngeal, and esophageal ( Logemann, 1983; Potulska, Friedman, Krolicki, & Spychala, 2003 ) It begins when food or liquid particles enter the oral cavity thro ugh feeding, are formed into a bolus by the oral cavity, and propelled into the pharynx and subsequently into the esophagus through the upper esophageal sphincter (UES). Swallowing involves muscles of the face, the palate, tongue and those involved in mas ti cation, as well as the suprahyoid muscles, which elevate the hyolaryngeal complex, and pharyngeal muscles, which help with bolus propulsion into the esophagus (Logemann, 1983; Dodds, Stewart, & Logemann, 1990 ) Diminished vertical elevation of the hyolar yngeal complex has been shown to decrease the ability of the UES to open and ease transfer of bolus into the esophagus ( Kendall & Leonard, 2001; Kendall Leonar d McKenzie, 2004 ) Accordingly, it has been found that decreased hyoid bone displacement, in i ndividuals with PD, is one cause of penetration and aspiration during swallowing (Troche et al., 2010). Kendall and Leonard (2001) found that older patients with swallowing difficulty versus younger patients with swallowing difficulty had a higher extent of hyoid displacement, but a lower duration of maximum elevation. The researchers of this study hypothesized that higher extent of hyoid displacement may be a compensation for slower initiation and duration of maximum excursion. Kendall, Leonard, and McK enzie (2004) discovered that healthy elderly subjects did not elevate the larynx or clear the pharynx to the same extent as younger control subjects, although point of maximum hyoid bone

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17 displacement did not differ between groups. The researchers indicate d that hyoid to larynx approximation is important for pharyngeal propulsion of the bolus. Dysphagia, or difficulty in swallowing, can occur at any of these three stages and Throughout this paper, dysphagia will refer specifically to oropharygeal dysphagia, difficulty that occurs when moving the bolus from the mouth to the esophagus (Davis, 1993; Groher & Crary, 2010). In rec ent years, dysphagia has been defined by Tanner (2006) as a deficit of sensory, cognitive, emotional, and/or motor acts involved in the transfer of a bolus from the mouth to reased It is estimated that as many as 95% of individuals with PD have deficits in swallowing function (Fox et al., 2006 ; Potulska et al., 2003 ; El Sharkawi et al 2002 ) Deteriorating swallowing function often causes aspiration of food and liquids into the lungs and su bsequent pneumonia, which is a major caus e of death in the PD population (Fernandez & Lapane, 2002; Hoehn &Yahr, 1967) In the oral phase, tremor in the oral cavity, piecemeal swallowing, repetitive tongue pumping and other aberrations in tongue movement, and impaired motility may occur (Potulska et al., 2003; Van Lieshout, Steele, a nd Lang, 2011). Difficulties associated with pharyngeal stage swallowing in those with PD include decreased hyolaryngeal excursion, deficient epiglottic positioning and range of motion, vallecular and pyriform residue, aspiration and penetration, and impaired motility (Leopold & Kagel, 1997; Groher & Crary, 2010 ; Troche et al., 2010 ). Dysfunction of the UES and delayed transport of the bolus in the esophageal phase can

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18 add to dysphagia severity in those with PD (Leopold & Kagel 1997; Potulska et al., 2003; Groher & Crary, 2010). A s tudy by Potulska and colleagues (2003) assessed the swallowing reflex and different stages of swallowing using electromyography (EMG) and esophagea l scinti graphy in 18 individuals with PD This study revealed delayed trigg ering of the swallowing reflex, prolongation of laryngeal movement during the pharyngeal phase of swallowing, and prolonged esophageal phase of swallowing occurred Furthermore, all participants demonstrated piecemeal deglutition, in w hich the participants took more than one swallow to clear one bolus into the esophagus This was seen in participants that had no complaints of dysphagia symptoms. This suggests that dysphagia may occur at a subclinical level in early stages of PD. Additionally, Van Lieshout, Steele, and Lang (2011) found that 10 patients with mild moderate PD showed smaller and more variable tongue movements in the horizontal plane, showing subclini cal change in earlier stages of PD than previously thought. Current Dysphagia Research Before 2008 studies investigating behavioral therapy for orophayngeal d ysphagia in patients with PD were diverse in therapeutic methods and outcome measures and most were non randomized clinical trials consisting of fewer than 12 participants (Baijens & Speyer, 2008). A recent exception to this finding includes a study of expiratory muscle s trength t raining (EMST) by Troche et al. (2010) of 60 patients with PD. Baijen s and Speyer (2008) in a review of dysphagia therapy in PD patients found that outcomes for behavioral treatment or swallowing training however, have been more positive in comparison to studies investigating surgical and medicinal interventions. For ex ample, a meta analysis by Menezes and Melo (2009) of five

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19 studies recounting swallowing function in patients using levodopa, none of these studies indicated that levodo pa intake had any effect, whereas LSVT (El Sharkawi et al., 2002) EMST (Pitts et al., 2009; Troche et al., 2010) and highly intensive speech therapy (Robertson & Thomson, 1984) have resulted in positive swallowing outcomes, with sample si zes of 8, 60, and 18, respectively (Russel, et al., 2010). L ong las ting therapeutic benefits for rehabilitation of PD have occur red when the ther apy is swallowing ganglia and importance of context on degrees of motor movement and impairment (Russel et al., 2010). Despite the expectation that benefit most likely would occur from dysphagia therapy involving swallowing specific tasks, both EMST and LSVT have documented positive swallowing outcomes for non swallowing specific activities These outcomes suggest s system shared central and peripheral circuits are activated (Russel et al., 2010). Findings from LSVT study by El Sharkawi and colleagues in 2002 discussed that positive swallowing outcomes may have originated from activation of n euromuscular control of the entire aerodigestic tract. Lee Silverman Voice Therapy, an established voice treatment for individuals with PD, has shown reductions in swallowing motility disorders and reduced te mporal measures in 8 subjects with PD (El Shar kawi et al., 2002). Although LSVT LOUD do es not specifical ly target swallow function, the exercises recruit many of the same muscles involved such as the submental muscles, and create positive outcomes for swallowing, possibly due to similarities in peri pheral and central neural control elements (Russel, Ciucci, Connor, & Schallert, 2010). Another study by Robertson and Thomson (1984)

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20 discovered that 40 hours over 2 weeks of intensive speech therapy targeting phonation, respiration, prosody, and articula tion resulted in significant improvement to swallow response time to solid food and liquid boluses for 18 subjects with PD. Established Dysphagia Treatments Current direct t reatments for dysphagia include a variety of specific swallowing maneuvers such as the Masako or tongue hold maneuver the Mendelsohn maneuver super supraglottic swallow, and the effortful s wallow (Lazarus, Logemann, Song, Rademaker, & Kahrilas, 2002; Ashford et al., 2009; Groher & Crary, 2010 ). Lazarus and associates (2002) report ed that these swallowing maneuvers improved tongue base pharyngeal wall pressures and increased contact duration in individuals with head and neck cancer. Kyng and colleagues (2010) in a neuroimaging study reported that both the effortful swallow and the Mendelsohn maneuver elicited higher responses in brain regions related to swallowing compared to a dry swallow, suggesting enhanced cortical activation during the tasks. Positional m odifications during the swallow such as tucking the chin down are common ly used to improve swallowing function and airway protection as well ( Welch, Logemann, Rademaker, & Kahrilas, 1993 ; Ashford et al., 2009 ) A review by Ashford and associates (2009) found, however, that although the chin tuck maneuver is used commonly, it provides only limited physiologic protection against aspiration for those with neurologic disorders, such as PD. The swallowing techniques listed above are task specif ic, as they strengthen s wallowing muscles and increase coordination through modified swa llowing tasks (Lazarus et al., 2002; Logemann, 1983) They can be used with or without a bolus depending upon the deficit of the patient.

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21 T he Masako or tongue hold maneuver, is complet ed when the patient swallow s while holding the tongue anterior to the teeth, thus causing the posterior pharyngeal wall to b ulge and create pressure that helps move the bolus into t he pharynx ( Fujui & Logemann, 1996; Fujui Kurachi, 2002 ). T he Mendelsoh n maneuver is completed by a ski ng the individual to hold an ongoing swallow at the top of hyolaryngeal excursion during swallow for a few seconds before relaxing and allowing the swallow to continue (Kahrilas, Logemann, Krugler, & Flanagan, 1991) In a study by Kahrilas and colleagues (1991) the Mendelsohn maneuver increased the duration of the anterio superior excursion of the hyoid and larynx and delayed sphincter closure by maintaining traction on the anterior wall of the sphincter. The Mendelsohn maneuver has been cited to improve total oral feeding in two thirds of 58 tube fed individuals with neurologic deficit s (Neumann et al 1995). The super supraglottic swallow requires a breath hold with effort during a swallow to target glottal closure and is designed to protect against a spiration (Donzelli & Brady, 2004) The effortful s wallow also called the forceful or hard swallow technique requires the patient in order to increase the forces of the structures inside the swallowing mechanism on the bo lus ( Pouderoux & Kahrilas, 1995) Hind, Nicosia, Roecker, Carnes, and Robbins (2001) found that 64 healthy middle aged and older men and women increased the duration of hyoid maximum anterior excursion, laryngeal clo sure, and UES opening after using the e ffortful swallowing maneuver A study by Felix, Correa, an d Soares (2008) found that the effortful s wallow improved clinical swallowing measures, such as the presence of coughing and choking after swallowing, alteration of vocal quality after swallowing, and residue in the oral cavity, especially when reinforced with biofeedback.

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22 Expi ratory muscle strength training on the other hand, is a recent ly established therapy that has been shown to improve swallowing and cough function (Pitts et al. 2009 Troche et al., 2010 ) Improved cough function is linked to EMST improveme nts in MEP A high maximum expiratory pressure is needed during a cough in o rder to aerosolize and dispel material from the airway. With the EMST device, users must create an isometric muscle contraction that is task specific training to voluntary and reflexive cough (Pitts et al 2009). It is, howeve r an example of a non task specific swallowing exercise that has strong evidence of efficacy. Troche and colleagues (2010), in a Class 1 randomized trial of sixty patients with PD have cited improvements to swallowing in those with PD after participation in a 4 week restorative program utilizing EMST as evidenced by improved p enetration a spiration scores (P A scores) most proba bly due to improvements to hyo laryngeal functioning Additionally, this study showed improvements to a swallowing quality of life measure (SWAL QOL), in creases to the extent of hyolaryngeal magnitude displacement (in millimeters) and stability in the duration of maximum hyolaryngeal magnitude displacement versus a sham group Music Therapy and PD Music therapy (MT) is defined as the intentional and planned use of music to being (Magee, Brumfitt, Freeman & Davidson, 2006). The field of formal music therapy began in the late 1940s, catalyzed by the large population of soldiers coming back to the United States from fighting in WWII with traumatic brain injuries from head wounds and post pg. 272 ). Healthcare professionals noticed that mus ic could decrease depression and pain, and improve blood pressure and pulse rates (Sacks, 2007, pg. 272) Additionally, a functional

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23 magnetic resonance imaging study has found that listening to and anticipating music has been shown to increase dopamine re lease in the striatal system in the basal ganglia (Salimpoor, Benovoy,Larcher, Dagher, & Zatorre, 2010). Music therapy has been proven to be effective in management of functio nal communication in those with PD in addition to other neurological deficits caused by Stroke and TBI A study by Masayuki and Kuzuhara (2008) found that eight participants with PD incr eased the number of steps walked and timing of steps after receiving one walking. Another randomized and controlled study by Pachetti and colleagues (2000) found that 16 patients with PD w ho participated in MT versus 16 patients with PD who participated in traditional physical therapy improved bradykinesia, a slowed ability to initiate and continue motor movements, Scale Motor Symptoms (Goetz et al., 2008). The MT group also improved emotional functions and Happiness Measure (Fordyce, 1988) The MT sessions consisted of choral singing, voice exercise, as well as free and rhythmic body mov ements. Maggee, Brumfitt, Freeman, and Davidson (2006), in a case study, revealed that after completing sessions of MT coupled with speech language therapy, a patient with P arkinsonian v ascular disease improved prosody, phonation, and measures of well being. This study utilized physical breathing, and vocal exercises Vocal exercises included singing on an ascending and desce nding scale and manipulating and timing single open vowe l sou nds on a single exhalation. The MT sessions also consisted of singing simple, familiar songs (Magee et al., 2006)

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24 Singing and Voice Treatment in PD As previously discussed, r ecent voice and swallowing research has highlighted the importance of intensive treatment with a requirement of high levels of physic al effort in order to improve speech and swa llowing symptoms in those with PD. A ccording to Ramig et al. ( 1995 ) patients also must be constantly motivated to high level of performance. In this conte xt, a group program involving singing activity may be beneficial to patients, as singing may be a motivating experience that requires high phonation effort and respiratory coordination (Haneishi, 2001) Additionally, Kleber, Veit, Birbaumer, Gruzelier, an d Lotze (2010) indicated that vocal skills training increased functional activation of the primary somatosensory cortex representing the larynx and articulators bilaterally. This study also demonstrated that expert classically trained singers showed incre ases of activation in the thalamus, cerebellum, and basal ganglia, areas responsible for enhanced sensorimotor regulation and kinesthetic motor control which are often impaired in individuals with PD Singing result s in higher vocal intensities (Tokinson 1994) than speaking, and may increase respiratory muscle strength (Wiens, Reimer, & Guyn, 1999). Singing classes have been used to increase maximum respiratory pressures in those with chronic obstructive pulmonary disease (Bonilha, Onofre Vieira, Prado, & Martinez, 2009). Musical and other Fine Arts activities have been established in the U.S. for patients with PD at Northwestern University Parkinson Diseas e and Movem ent Disorders Center (Science Daily, 2011) A controlled and randomized study by Modugno and colleagues (2010) reported that participation in an active theater program improved ratings of the (Goetz et al., 2008) f or 10 subjects with PD.

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25 Recent studies investigating the role of individual and choral singing on voice function in PD have revealed positive results. Haneishi (2001) discovered increased vocal intensity, improved speech intelligibility, and increased du ration of maximal sustained phonation in four female participants after they were involved in Music Therapy Voice Protocol (MTVP). This intervention used vocal warm ups and singing exercises for the duration of 12 14 sessions. Another study, by D i Benedet to and colleagues (2009), found that choral singing if employing prosodic, respiratory and laryngeal exercise may lead to improvements in reading and vowel phonation. This study demonstrated that voice choral singing therapy (VCST) improved respiratory p ressures (MEP and MIP) and vol umes, increased maximum phonation time (MPT) and reduced vocal fatigue in 13 male and 7 female subjects with PD. T hese types of improvements did not transfer well to benefit overall vocal quality however S hort term versus long term effects were not examined. It was noted, however, that the participants showed good treatment compliance, which was consistent with their hypothesis that choral singi ng might show comparable or higher participation compliance than traditional t her apies ( D i Benedetto et al 2009) According to Wan, Ruber, Hohmann, and Gottfried (2009), although these two studies had relatively small sample sizes, the results of both studies show that singing may help to better speech deficits and that a therapy employing choral singing is wort hy of further investigation. These two studies represent only preliminary evidence and there is little indication that a program integrating MT and voice therapy would result in positive physiologic voice and swallowing disorde rs in individuals with PD. The therapy provi ded in the current study targeted respiratory, swallowing and voice function allowing for more

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26 support of a larger con trolled study investigating interdisciplinary choral singing therapy (ICST) Interd isc iplinary choral singing therapy was designed to utilize choral singing techniques combining both voice therapy and MT paradigms. The a ims and h ypothese s for this study are as follows : Aim 1: To examine effects of ICST on ph ysiologic and perceived cha nges in the voice. H ypothesi s 1: Interdisciplinary choral singing therapy will increase measures of respiratory pressure and vocal functioning, and will improve voice related quality of life Aim 2: To examine effects of ICST on physiologic and perceived changes in the swallowing mechanism. Hypothesis 2: Interdisciplinary choral singing therapy will increase hyoid bone angle and magnitude di splacement, improve penetration aspiration s core s and improve swallowing related quality of life

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27 CHAPTER 2 METHODS Participants Participants were three men, between the ages of 67 and 85 years of age, who (PD) by neurol ogists at the Center for Movement Disorders and Neurorestoration at the University of Flori da They were recruited from local support groups and from the Center for Movement Disorders and Neurorestoration at the University of Florida. Two participants had received at least one session of swallowing or speech /voice therapy since receiving their diagnosis of PD. Two participants had sung in church choirs in the past 10 years See Table 2.1 for inclusion and exclusion criteria. Table 2 1. Inclusion and exclusion criteria # Inclusion Criteria 1. A clinical diagnosis of idiopathic PD using the UK Brain Bank criteria, made by a neurologist specializing in movement disorders. 2. 3. Age between 60 85 years 4. A stable regimen of antiparkinsonian and psychotropic medications for 30 days prior to participation. 5. Non smoking or no smoking within the previous 5 years. 6. Sufficient facial muscle strength in order to achieve and maintain lip closure around a circular mouthpiece. # Exclusion Criteria 1. Significant cognitive impairment (MMSE<24) 2. Major psychiatric disorder(major depression, generalized anxiety, schizophrenia) 3. History of head and neck cancer 4. History of asthma 5. History of COPD 6. History of untreated hypertension Dropouts and Adherence Participants were expected to commit for roughly 10 weeks, including the interventions and assessments. Adherence of over 80% was expected, while adherence of 100% was achieved Intervention was provided over a perio d of 9 weeks

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28 All participants attended 8 out of 9 group sessions. This study was approved by the University of Flo rida Institutional Review Board (104 2011) Data Collection P re and Post I ntervention Evaluations were conducted pre and post intervention The duration of the voice and swallowing evaluations was approximately 2.5 hours due to collection of other measures that are a part of a larger research study, not discussed in this paper All evaluations were conducted at the University of F lorida Speech and Hearing Clinic and Radiology D epartment of UF Shands staff assistants. To reduce the potential effects of waning medication on performance, ients and at the time of evaluation were in the 2 hours of taking anti parkinsonian medicine). The pre and post evaluations were completed at the same time of day, in order to minimize potential med icati on and fatigue effects. Informed consent was obtained in accordance with UF institutional review board standards. During the voice evaluation the maximum phonation time (MPT) for sustained vowels, maximum frequency range (MFR) maximum sound pressure l evel ( SPL) MEPs and MIPs were collected These maximum performance tests are commonly used to evaluate speech and voice in speech language pathology and normative data is available and adequate (Kent, Kent, & Rosenbek, 1987) The MPT of vowels /a/ and / i/ were obtained over three trials at a comfortable pitch and loudness level for the participant. The longest duration trial out of three was recorded. The MFR wa s detected through a mic rophone held at a constant 15 centimeter distance from the part icipa nt. Three trials each of ascending and descend ing glides were performed Maximum frequency range was analyzed using Kay Elemetrics Computerized Speech

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29 Lab version (4500) software. The maximum ascending frequency from 3 trials and minimum descending frequ ency of three trials was recorded. Finally, the SPL of the vowel /a / was collected by a digital sound pressure level meter model 33 2055 A, a t the standard distance of 30 centimeters as the participant maintained loudness at a mid range frequency. The averag e of three trials was recorded due to a wide range observed within the pre testing scores. Finally, MEP s and MIPs were obtaine d through the use of a Micro Direct Respiratory Pressure Meter ( htt p://www.microdirect.com/microRPM.asp ) al so called a manometer Approximately six trials for both MEP and MIP were collec ted. The average of the best three trials each for MEP and MIP were reported Videoflouroscopic P rocedure Pre and P ost I nterventio n Swallowing function was assessed pre and post intervention, utilizing modified barium swallow stud y (MBS) and administration of a psychometrically sound dysphagia specific quality of life measure called SWAL QOL (McHorney et al., 2000; McHorney, Marti n Harris Robbins, & Rosenbek, 2006) The SWAL QOL is a subjective measure on a Likert scale ranging from 1 5. A score of a 5 indicates that the statement in question is no problem or no concern wher eas a score of 1 indicates great problem or great conce rn. The SWAL QOL was completed by the patient prior to undergoing the MBS study during pre and post testing A speech language pathologist attended and directed the participant during each MBS study. Each MBS study was performed at the Radiology departm ent of UF Shands in Gainesville, FL. A penny (length=18 mm on x ray image ) was used as a reference point, needed for measuring hyoid bone displacement The penny was placed on the videoflouroscope to mark the anterio r temporal bone of each patient. During the

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30 fluoroscopic swallow study participants were seated in a chair with shoulders down and hands placed in the lap. Left lateral images were taken as participants were asked to con secutively swallow three trials o f 10 cc th in liquid barium, followed by three trials of 10 cc. pudding thick barium contrast. Singing Therapy Intervention Procedures Each group session took place at the Language over the Lifespan Laboratory at the University of Florida. Each session b egan and ended with social interaction activity songs. The song title for commencemen a by Al Hoffman, Bob Merrill, and Clem Watts, published in 1950 The commencement song req uired shaking of hands, eye contact, and smiling. After the greeting, the participants engaged in a series of vocal exercises non singing exercises targeting forward resonance, pitch range, respiratory coordination during phonation and articulation. Vocal exercises were followed by choral singing of familiar songs The song title for ending the session was a folk song made famous in its 1925 adaptation by James Campbell and Reginald Connelly Songs u tilized were familiar to the participants. Each song consisted of a simple rhythm and melody. Vocal Exercises Lip buzzing was the first vocal exercise that the participants were asked to perform L ip buzzing involves pushing air through approximated u pper and lower lip resulting in a buzzing sound from the lip vibrations. The exercise was designed to target both respiratory coordination and forward vocal focus The exercise was tiered weekly to a llow for a progression to more difficult tasks. First, participants were asked to lip buzz with a straw, then without the straw but with no phonation If they performed

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31 th e task well, they progressed to a lip buzz using phonation at medium, high, and low pitches. Finally, participants maintained the lip buz zing while sliding from low to high and then high to low pitches during a glissando Next, p articipants were asked to perform glissandos using an open mouth, in order to target and expand vocal range. The task began by sliding, or slowly and gently changi ng pitch, an interval of a third and systematically progressed to sliding at an interval of an octave. to maintain a straight posture, and to monitor abdominal breathing In later sessions, visuali zations and hand movements were introduced to help the participants achieve forward resonance. Messa di Voce exercises were performed in order to increase control of vocal intensity or loudness level The participants held a single pitch for five seconds while gradually increasing their i ntensity level after the first two seconds. The expected loudness level for each participant was based upon dB SPL measures collected previous to intervention sessions The loudness level increased from a soft p honation the five second task. Maxim um loudness levels were recorded each week by utilizing a Radioshack digital sound pressure level meters held at a constant 30 centimeter distance from the mouths of the part icipants In order to reduce additive effect caused by recording in a group setting, all participants were seated equidistant from one another and all participants had an assigned chair which remained constant throughout the sessions. Measures collected during the sessions were used to provide visual and numerical feedback to the

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32 participants during vocal exercises and singing and should not be taken as absolute measures. A rticulation exercises were utilized in order to encourage active movement of the lips, tong ue, and jaw. Participants sang a five step scale using the nasal consonant /m/ in single in order to encourage forward resonance The initial consonan t progressed weekly from nasal /m/ to non nasal /t/, /d/, / k/, and /s/ during repetitions of the scale. The tempo was kept at a constant 100 beats per minute in order to allow the participants to concentrate on producing exaggerated crisp consonants an d to regulate rhythm of speech. Choral Singing Choral singing utilized two popula r songs from the 1940 s and Charles Mitchell, publish ed in 1940 Familiarity was important in order to allow the participants to focus on therapy targets during the song s reducing cognitive load. While singing number of syllables sung using on e breath. They were asked to increase phonation time from approximately 5 syllables sung per breath to 10 syllables sung per breath Th is task was designed to target the respiratory system in order to increase respiratory coordination and MPT For the participants were encouraged to maintain clea r consonant articulation and melodic pitch. In addition, participants were required to sustain a set sound pressure level as measu re d by a dB SPL sound level meter when singing each song. Distance from dB SPL meter was held constant at 30 cm for multiple trials during singing. The expected sound pressure level was typically at

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33 or above baseline or immediate preceding loudness levels. As all loudness levels were collected simultaneously du ring group singing. This was done both to provide feedback to the participants about their loudness level, and to eliminate anxiety about singing alone in front of a group. An additive effect to intensity data collected during singing sessions should be considered. Data Analysis Mean s and standard deviation s f or the voice measures were calculated Statistical analysis was not completed due to the small n value (n=3). The greatest MPT out of three trials pre and post treatment was recorded for data ana lysis. Maximum frequency range was originally measured in Hertz. We measured the maximum difference between the lowest and highest fundamental frequency during glissando tasks, and then converted to the linear scale of semitones (ST). Maximum sound pres sure level was recorded in dB SPL collected from the sound pressure level meter mentioned above. Maximum expiratory pressure s and maximum inspiratory pressures were taken pre and post intervention using a manometer mentioned above. The P enetration A spiration (P A ) Scale is a visually rated scale describing the presence and extent of penetration or aspiration during videoflouroscopic barium swallow study (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) Three graduate student clin icians (two independent and the author), experienced in rating using this scale rated participant 1 3 for swallows of 10 cc of thin liquid barium according to the criteria (Table 2 2).

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34 Table 2 2. Penetration Aspiration Sc ale 1 Contrast does not enter the airway 2 Contrast enters the airway, remains above the vocal folds 3 Contrast remains above the vocal folds with visible residue 4 Contrast contacts vocal folds, no residue 5 Contrast contacts vocal folds, visible residue 6 Contrast passes glottis, no sub glottic residue 7 Contrast passes glottis, visible sub glottic residue despite patient response 8 Contrast passes glottis, visible sub glottic residue, absent of patient response Hyoid bone displaceme nt was calculated using a MATLAB routine entitled ainrand Mainrand is a program developed by the Laryngeal Function Laboratory at University of Florida that measures hyoid bone displacement frame by frame, point referenced, over time (Wheeler, Martin Harris, Brodsky, Thekkevalappil & Sapienza, 2006) The program measures the distance traveled by the hyoid bone and corresponding angle of hyoid elevation with reference to the third cervical vertebra (C3). T he pharyngeal phase of the swallow was measured for thin liquid and pudding thick bolus consistencies (Figure 2 2 )

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35 Figure 2 2 Example of measurements the Mainrand MATLAB routine makes during task analysis. H1=hyoid starting point in the first frame, H2=hyoid location in subsequent frame of the task, C3=third cervi cal vertebra (Wheeler Hegland, Rosenbek, & Sapienza, 2008) To use Mainrand routine in MATLAB (version 7.1), JPEG images were extracted from video recordings These images were created by independent computer technical support personnel of the Speech and Hearing Sciences at the University of Florida. Mainrand uses the first frame in the sequence of images as a reference line between the hyoid bone and the C3 (Wheeler Hegland, Rosenbek, & Sapienza, 2008). The most anterior inferior corners of C3 were mar ked and the most anterior superior corners of the hyoid bone were marked in all frames by the raters, in randomized order. When marking of reference points was completed, Mainrand

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36 calculated the angle (in degrees) and magnitude displacement as a ratio to the first frame ( in millimeters) of hyoid elevation into Microsoft Excel (Windows 7). Points of maximum angle and magnitude displacement were extracted from the Measures dis cussed include the following: A1: Angle of hyoid elevation at the point of maximum magnitude displacement A2: Maximum angle of hyoid elevation A3: Range of angle of hyoid elevation D1: Maximum hyoid magnitude displacement (anterior excursion) D2: Hyoid magnitude displacement at the maximum angle of elevation D3: Range of hyoid displacement

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37 CHAPTER 3 RESULTS Voice Measures MPT After treatment, two out of three participants improved MPT (in seconds) for the vowel /a/ (Figure 3 1 ). Participant 1 decreased by 4.2%, participant 2 increased by 161.5%, and participant 3 increased by 33.3%. Overall, MPT for /a/ increased by 47.3% (pre = 18.33 5.51 range = 13.0 24.0; post = 27.0 6.08 range = 23.0 34.0). Two out of three participants improved MPT for the vowel /i/ post treatm ent (Figure 3 2 ) Participant 1 decreased by 4.5%, participant 2 increased by 44.4%, and participant 3 increased by 30.0%. Overall, MPT for /i/ increased by 14.1% (pre=21. 33 3.06, range=18 2 4 ; post = 24.33 2.89, range=21 26 ). Figure 3 1 Maximum phonation time of /a/ (in seconds) pre to post treatment Pre-ICST Post-ICST Participant 1 24 23 Participant 2 13 34 Participant 3 18 24 10 15 20 25 30 35 40 Seconds MPT for /a/

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38 Figure 3 2 Maximum phonation time of /i/ (in seconds) from pre to post treatment M FR Only one participant increased MFR (i n semitones) after treatment (Figure 3 3 ) Participant 1 increased by 33.5%, participant 2 decreased by 21.1%, and participant 3 decreased by 10.1%. Overall, there was a 3.04% decrease in the MFR (pre=33.78 4.89, post=32.76 3.61) (Figure 3 6) Pre-ICST Pre-ICST Participant 1 22 21 Participant 2 18 26 Participant 3 20 26 10 12 14 16 18 20 22 24 26 28 Seconds MPT of /i/

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39 Figure 3 3 Individual MFR (in semitones) from pre to post treatment SPL After completing treatment, all three partic ipants demonstrated greater SPL than fro m pre treatment data collection. Participant 1 increased from pre to post by 10 dB, participa nt 2 increased and from pre to post treatment by 4.34 dB, and participant 3 increased from pre to po st dB by 6.34 dB( Figure 3 4) In addit ion to individual sound pressure level scores recorded pre and post intervention, SPL measures were collected during each ICST intervention session as well. All three participants gradually increased their SPL during Messa di Voce exercises and singing in unison each week (F igure B 1 and B 2 in Appendix B ). Pre-ICST Post-ICST Participant 1 28.28 37.74 Participant 2 37.65 29.69 Participant 3 35.42 31.84 20 22 24 26 28 30 32 34 36 38 40 Semitones MFR in Semitones

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40 Figure 3 4 Individual SPL ( in dB SPL ) from pre to post treatment M EP After the completing I CST, MEP increased for all three participants (Figure 3 5 ) Participant 1 increased by 1.3%, participant 2 increased by 16.7%, and participant 3 increased by 6.5%. Overall, MEP increased improved by 8.2 % (pre = 74.6 cm H 2 0 11.7, range = 54.0 94.7 cm H 2 0 ; post = 82. 8 cm H 2 0 13.4, rang e = 63.7 108.7 cm H 2 0 ). Pre-ICST Post-ICST Participant 1 80.33 90.33 Participant 2 79.33 83.67 Participant 3 97.33 103.67 70 75 80 85 90 95 100 105 dB SPL SPL in dB

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41 Figure 3 5 Individual MEP (in cm H 2 0) from pre to post treatment M IP Only one participant increased MIP after participating in ICST (Figure 3 6 ) Participant 1 decreased by 10.8%, participant 2 increased by 58.8%, and participant 3 decreased by 4.8%. Overall, MIP increased by 2.8% (pre = 58.9 cm H 2 0 13.5, range = 34.0 80.33 cm H 2 0 ; post = 61.7 cm H 2 0 5.2, range = 54.0 71 .7 cm H 2 0 ). Pre-ICST Post-ICST Participant 1 75 76 Participant 2 54 63 Participant 3 97.33 103.67 50 60 70 80 90 100 110 cm H20 MEP in cm H20

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42 Figure 3 6 Individual MIP (in cm H 2 0) from pre to post treatment V R QOL Improvement in V RQ OL is indicated by a decreasing score, indicating a decrease in voice related difficulties from during daily life where as higher scores indicate an increase in frequency and extent of voice difficulties or problems ( Hogikyan & Sethuraman, 1998) Only participant 2 displayed an improved V RQOL score from pre to post intervention ( Figure 3 7 ) When converting the raw score i nto a linear 0 100 metric, participant 1 only lowered perceived functioning by 8%, whereas participant 2 improved perceived functioning by 24% and participant 3 lowered perceived functioning by 20%. All participants perceived themselves as having a fair t o excellent voice related qua lity of life pre and post ICST, according to the perceptual descriptions found on the second page of the V RQOL. Pre-ICST Post-ICST Participant 1 80.33 71.67 Participant 2 34 54 Participant 3 62.33 59.33 30 40 50 60 70 80 cm H20 MIP in cm H20

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43 Figure 3 7 Individual V RQOL scores from pre to post treatment Swallowing Measures Participant 1 was exclud ed from swallowing measures, due to a technical issue involving M BS recording. I ncreases in both a ngle of elevation and magnitude displacement of hyoid bone for 10 mL thin liquid and pudding thick barium swallows occurred for participant 2 Increases in angle of hyoid elevation occurred for participant 3. Increased angle reflects vertical movement of the hyoid bone during swallo wing a nd increased magnitude indicates horizontal excursion of the hyoid bone during swallowing. Two graduate stud ents in speech language pathology (one independent and the author) marked the magnitude and angle between the hyoid bone and the third cervical vertebrae, frame by frame, in randomized order. The independent rater was a doctoral student who was licensed i n speech pathology for over two years. The author was a Master of Arts student in speech language pathology, who was trained in MBS interpretation through clinical placements at the University of Florida over 3 academic Pre-ICST Post-ICST Participant 1 12 13 Participant 2 17 13 Participant 3 15 18 10 11 12 13 14 15 16 17 18 19 20 Raw Score V RQOL Scores

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44 semesters. Inter rater reliability for hyoid b one displacement sh owed an agreement ranging between r= 0.80 to r=1.00 Hyoid Bone Displacement Measures Hyoid b one a ngle of e levation Both participants showed increases in hyoid bone angle of elevation pre and post I CST. Increases in participa nt 2 were t he greater than in participant 3. Within participant 2, greater improvements were found when swallowing thin liquid barium than swallowing pudding thick barium (Figure 3 8 ). W hen swallowing thin liquid barium, A1 increased by 95%, A2 increased by 113%, and A3 increased by 95% from pre t o p ost data collection (Table A 8 in A ppendix A ). During p udding thick bariu m swallows, A1 increased by 11% A2 increased by 0 .34%, and A3 decreased by 0 .41% (Table A 9 in A ppendix A ) Figure 3 8 Participant 2 angle of elevation (in degrees) while swallowing thin liquid and pudding thick barium consistencies Participant 3 demonstrated less angle of elevation increase from pre to post than participant 2. When swallowing thin liquid barium, the participant decreased angle of 0 5 10 15 20 25 30 35 Pudding(A1) Pudding(A2) Pudding(A3) Thin(A1) Thin(A2) Thin(A3) Pre-ICST Post-ICST

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45 hyoid elevation on all three measures whereas the participant increased all angle measures when swallowing pudding thick liquid barium (Figure 3 9 ) For thin liquid, A1 decreased by 43%, A2 decreased by 19%, an d A3 decrease d by 18% (Table A 10 in A ppendix A ). For pudding thick barium, A1 increased by 42%, A2 increased by 16%, an d A3 increased by 16% (Table A 11 in A ppendix A ). Figure 3 9 Participant 3 angle of elevation (in degrees) for thin and thick liquid swallows Hyoid b one magnitude d isplacement Only participant 2 showed improvements in magnitude hyoid bone displacement, which was calculated by the taking the ratio of length, in millimeters, between C3 and the hyoid bone of each frame to the length found at res t (first frame in sequence). This participant showed similar increases in all displacement measures when swallowing thin and pudding thick liquid barium (Figure 3 10 ). When swallowing thin liquid, D1 increased by 3%, D2 increased by 14%, and D3 increased b y 9% from pre to post intervention data collection (Table A 12 in A ppendix A ) When swallowing pudding thick 0 2 4 6 8 10 12 14 16 Pudding(A1) Pudding(A2) Pudding (A3) Thin(A1) Thin(A2) Thin(A3) Pre-ICST Post-ICST

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46 barium, D1 increased by 4%, D2 increased by 6%, and D3 increased by 20% from pre to post interv ention data collection(Table A 13 in A ppendix A ). Figure 3 10 Participant 2 magnitude hyoid displacement ( in millimeters) for thin and thick liquid swallows Pa rticipant 3 demonstrated some decreases in hyoid magnitude displacements during thin liquid an d pudding thick barium swallows Small decreases in hyoid displacement were similar for both thin liquid and pudding thick b arium consistencies (Figure 3 11 ). For thin liquid, D1 decreased by 0.1%, D2 decreased by 2%, and D3 decreased by 6% from pre to post interv ention data collection(Table A 14 in A pp endix A ). For pudding thick barium, D1 decreased by 5%, D2 decreased by 3%, and D3 decreased by 12% from pre to post interve ntion data collection (Table A 15 in A ppendix A ). 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Pudding(D1) Pudding(D2) Pudding(D3) Thin (D1) Thin (D2) Thin (D3) Pre-ICST Post-ICST

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47 Figure 3 11 Participant 3 magnitude hyoid displacement (in millimeters) for t hin and pudding thick liquid swallows P A Score Three graduate student clinicians (two independent s and the author), t rained by the Center for Movement Disorders and Neurorestoration at UF for 3 6 months, rated participant 1 3 for swallows of thin liquid barium using the P A scale Swallowing sequences were displayed out of order. The independent raters were blinded to the order and the participant number. Inter reliability range was r=.59 to r=.82 according to P A scale criteria. Participant 1 Showed penetration to the level of the vocal folds with visible residue on 1/3 swallowing sequences pre ICST and showed less deep penetration without visible residue on 2/3 swallowing sequences post ICST. That marks an improvement in P A score. Participant 2 di splayed penetration to the level of the vocal folds with some visible residue on 1/3 swallowing sequences pre ICST, and 1/3 swallowing sequences post ICST signifying no change from pre to post intervention Participant 3 increased 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Pudding(D1) Pudding(D2) Pudding(D3) Thin(D1) Thin(D2) Thin(D3) Pre-ICST Post-ICST

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48 in P A score during post ICST data collection. This participant displayed penetration above the vocal folds with visible residue post ICST ( Table 3 1 ) Table 3 1 Penetration A spiration Scale scores pre and post intervention for thin liquid barium swallows Participant Pre ICST Post ICST Change 1 5 2.67 Improv ement 2 4.67 4 .67 No change 3 3.33 3 Mild improvement SWAL QOL Participant 1 and 3 worsened in their overall score by > 10 points. Participant 2 increased the overall score by one, thus representing no measurable change from pre to post intervention in perceived swallowing day to day functioning(Figure 3 11) Figure 3 12. SWAL QOL overall score pre and post treatment Pre-ICST Post-ICST Participant 1 203 185 Participant 2 197 198 Participant 3 205 195 Raw Score Ratings Swallowing Quality of Life Rating Pre and Post Treatment

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49 CHAPTER 4 DISCUSSION Voice Outcomes As hypothesized, increases we re found for MPT of /a/ and /i/. Maximum phonation time depends on respiratory volume, specifically vital capacity, and laryngeal airflow, or the time derivative of the volume of air moving through the larynx during phonation for each individual (Kent, Kent, & Rosenbek, 1987). Ptacek et al. (1966) reported the mean maximum phonation duration (time) on /a/ for healthy men bet ween the ages of 68 89 years as 18.1 seconds, with a standard deviation (SD) of 6.6. Increases in MPT for the vowel /a/ have been reported in both singing interventio n studies Haneishi (2001) a nd D i Benedetto and colleagues ( 2009) A case study integrating MT and speech/voice therapy also improved this measure in an individual with pseudo Parkinsonian vascular disease (Magee et al., 2006). The study by D i Benedetto a nd colleagues (2009) investigating VCST found significant increases to this measure (n=20, P=0.000). Haneishi (2001), investigating an individual singing therapy MTVP reported non stat istically significant increases in part due to a low sample size (n =4 P= .311 ) after a paired t test. A difference between the current study and past research investigating singing therapy in PD is that the patients involved in VCST ( D i Benedetto et al., 2009) received approximatel y 4 hours per week of speech therap y and choral singing separately over 10 weeks whereas the current study provided 1 hour per week of combined speech/voice and choral singing therapy over 8 weeks. It was surprising that although increases were found for all participants in SPL, MPT, and MEP measures, only participant 1 increased in MFR. The previous studies

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50 me ntioned above (Haneishi, 2001; D i Benedetto et al., 2009) did not inve stigate MFR, but did find increased fundamental frequency variability or prosody during phonation of five consecutive wo rds, sentences, and connected speech samples Variability in MFR, also called fundamental frequency range (FFR) or phonatory frequency range has been reported (Hollien, Dew, & Philips, 1971). One study by Gelfer (1986 ) indicated a mean intra subject variation of 2 semitones (ST) within a single d ay, and greater variation between 4 6 weeks without intervention In a study by Gamboa and colleagues (1997), 16 male healthy control subjects and 24 males with PD within a similar age gro up had a phonatory frequency range of appro ximately 20.9 ST and 18.4 ST during connected speech, whereas Ramig and Ringel (1983) reported that healthy geriatric adults had a mean pitch range of 31.4 ST with an SD of 4.4 During pre testing of the current study all participants sc ored within the normal range of the ir peers, 31.4+/ 4.4 as reported in Ramig and Ringel (1983). Participant 1 scored at the bottom of this reported range however Furthermore, participant 1 was the only participant who did no t have previous singing experience via singing lessons, singing solos, or with choral singing. This may represent a ceiling effect for the other two participants, who displayed a higher frequency range during pre testing. As hypothesized, i ncreases in S PL were discovered post ICST for all three participants Increases from pre to post intervention ranged from 4.3 to 10.0 dB with an average increase of 6.9 dB for the group. Ptacek et al. (1966) found that geriatric men on the vowel /a/ and at 30.48 cm. mike to mouth distance had an average SPL of 100.5 dB +/ 5.9. Both participants 1 and 2 had pre testing scores below the mean reported by Ptacek et al. (1996), but showed increases post testing.

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51 Haneishi (2001) found that four female subjects with PD showed increase s in vocal intensity of 10 dB from pre to post treatment The increases in SPL found in the current study are a lso similar to those found in studies investigating LSVT although therapy sessions in the current study were much less intensive Ramig and colleagues (2001) reported an average increase of 8 dB immediately post LSVT and a maintained average increase of 6 dB from baseline at a 6 month follow up for 14 partici pants. Additionally, in a study of 12 participants with PD, Spielman and colleagues (2007) found an increase of 8 dB immediately after an extended version of LSVT and maintenance of a 7.2 dB increase from 6 months later. Both the current study and LSVT r esearch studies prompted and/or provided feedback to participants in order to increase participant SPL during the therapy sessions. One conclusi on that could be made about SPL scores in the current study is that increases found pre and post intervention could be attr ibuted to the practice effect. Th is effect was expected as dB scores from a sound pressure level meter were used as feed back for participants during all singing sessions (Figure B 1 & B 2 in A ppendix B) Moreover, MEP increased for all part icipants while MIP scores showed improvement for only one participant Statistically significant i mprovements in MEP were discovered in the study (n=20, P=0.006) by D i Benedetto and associates ( 2009). Normative MEP and MIP means for the age groups 60 69 years and above 69 years have been reported on by Brit to, Zampa, de Oliveira, Prado, and Parreira (2009). This study found that between the ages of 60 69 years the mean MEP value was 102.08 +/ 47.89 cm H 2 0 and the mean MIP value was 54.58+/ 32 .37 cm H 2 0 Participant s 1 and 3 lay within this age range. Pre ICST, the participants scored below the mean for MEP,

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52 but above the mean for MIP. This may have reflected a ceiling effect for the MIP scores of participant s 1 and 3 Participant 3 improved MEP post intervention to above the no rmal mean, whereas participant 1 s howed less improvement. Above the age of 69 years the mean MEP value was 87.92+/ 59.71 cm H 2 0 and the mean MIP value was 54.58 +/ 33.61 cm H 2 0 (Britto et al., 2009). Participant 2 was with in this age range. During pre testing, t his participant scored below the mean for both MEP and MIP. After completing ICST, both MEP and MIP scores increased for participant 2. Maximum inspiratory post testing scores were similar to those of norms denot ing a larger improvement than in MEP, although MEP increased by 16.7% post testing. In the current study, it was observed that two out of three participants showed more difficulty during pre and post data collection in completing the task to measure i nspiratory versus expiratory pressure. Improvements to MEP cannot be entirely explained by the practice effect, although participants in the current study were asked to coordinate respira tion by taking deep breaths, phonating while activating abdominal mu scles and maintaining loudness during voice therapy and singing tasks Wilson and colleagues ( 1984) report ed that the measurement of MEP and MIP can be a simple and reproducible me asure of respiratory muscle functioning and the progression of weakness of the respiratory system ( p. 538). Therefore, improvements in MEP may be due to improved respiratory strength or coordination from phonation tasks associated with ICST. Lack of aver age improvement for MIP scores was somewhat expected, because the treatment did not specifically target this outcome. The V RQOL measures were more variable between participants than hypo thesized, as participant 2 improved scores, participant 3 worsene d scores, and

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53 participant 1 did not show great change in scores post treatment (Hogikyan & Sethuraman, 1998) When converting the raw score into a linear 0 100 metric, participant 1 only lowered perceived functioning by 8%, whereas participant 2 improved perceived functioning by 24% and participant 3 lowered perceived functioning by 20% Group voice therapy by Searl et al. (2001) has shown increases to perceptions of vocal quality for 15 individuals with PD via the Voice Handicap Index (VHI), a questionna ire highly correlated with the V RQOL ( Portone, Hapner, McGregor, Otto, & Johns, 2007 ). Although using specific voice related quality of life measures is useful, it has been shown to have no significant correlation to the Dysphonia Severity Index (DSI), a more objective measure of vocal functioning (Schneider, Plank, Eysholdt, Schutzenberger, & Rosanowski, 2011). Variability of this outcome in the current study, may be due to increased awareness of vocal deficits for some patients in this study. Partici pant 3 reported increased awareness of vocal deficits during a singing session conducted prior to post testing. Supporting this, it has been documented that those with PD experience sensorimotor deficits that may cause them to overestimate vocal function when lacking feedback from the listener, particularly in regard to vocal loudness ( Ho, Bradshaw, & Iansek, 2000). During the ICST intervention, feedback concerning vocal functioning was frequently given to the participants. Swallowing Outcomes Data sho wed incre ases to hyoid bone superior and anterior displacement within the participants from pre to post testing Increases in angle of elevation were found for both participants and increases in magnitude displacement for one participant. Results from this study are most similar to results from EMST investigations by Troche and colleagues (2010), in that hyoid bone magnitude displacement (anterior excursion)

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54 increased due to a non swallowing specific intervention for those 55 85 years of age with moderate PD (n=60) Hyoid bone displacement duration and other measures Troche et al. (2010). Like the current study, t his study also found improvements in P A scores as we ll as other measures related hyo laryngeal functioning. There is currently no normative data on the specific angle and magnitude displacem ent included in this study for healthy older adults; however, p re testing scores of A1, A2, D1, and D2 with thin liqui d barium for both participants were similar to the data of younger individuals in a study by Wheeler Hegland and associates ( 2008) In the previously mentioned study (Wheeler Hegland et al., 2008), t he mean hyoid elevation for A1 and A2 was reported as 7. 49 degrees and 10.39 degrees respectively. The mean hyoid magnitude displacement for D1 and D2 was 1.42 millimeters and 1.22 millimeters respectively D ifferences were observed between the current study po pulation and the normative data on younger adults (Wheeler Hegland et al. 2008) for swallows of 10 mL thin liquid barium. Participant 2 had an A1 below the mean reported by Wheeler Hegland and associates (2008) during pre testing of thin liquid barium, but increased to have an A1 above the reported mean which indicates improvement. Participant 2 also exhibited a post testing score for A2 much greater than the mean rep orted in Wheeler Hegland and associates (2008). This could reflect a difference between the age groups as seen in a previous study by K endall, and Leonard (2001) This study reported that older adults (67 83 years) compared with younger adults (18 62 years) showed greater extent of hyoid displacement but a shorter duration of hyoid elevation. The researchers hypothesized that greater ex tent of hyoid displacement found in the

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55 older adult group may be a compensation for a shorter duration of hyoid maximal elevation and thus shorter duration of UES opening. Participant 3 showed a mild decrease in the angle of elevation from pre to post tes ting for thin liquid barium consistency The ceiling effect could have contributed to this outcome, with consideration that this participant exhibited higher pre testing scores of A1 and A2 when compared to normative data from young adults (Wheeler Heglan d et al. 2008). In reference to magnitude displacement (D1 and D2) for swallows of 10 mL of thin liquid barium, both participants displayed lower pre testing scores than the young healthy adult data (Wheeler Hegland et al., 2008) with the exception of D1 for participant 2. A ceiling effect was observed in this measure for participant 2, as pre testing scores for magnitude displacement were closer to the mean reported by Whee ler Hegland and associates (2008). Participant 2 also exhibited a smaller amount of change from pre to post data collection session for this measure Participant 3 exhibited decreases to magnitude of hyoid bone displacement for 10 mL thin liquid barium bolus. It should be noted that the study by Wheeler Hegland and associates (2008) did not investigate swallowing displacement during swallows of pudding thick barium co nsistency. Both participants showed increases to both angle and magnitude hyoid displacement for swallows of pudding thick cons istency, however, i t was observed that the frequency of piecemeal swallowing also called piecemeal deglutition, for pudding thick liquid consistency increased from pre to post data collection sessions. Piecemeal swallowing is an early swallowing problem for individuals wit h PD (Potulska et al., 2003;

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56 Groher & Crary, 2010). This difference may affect further comparisons to younger subjects and to individuals with PD, who do not exhibit piecemeal deglutition. Penetration A spiration scores from pre to post ICST were more v ariable than hypothesized This is surprising as Troche and associates (2010) found significant improvement to P A scores in addition to hyoid bone magnitude displacement in a study of the swallowing related task of EMST, which also has been shown to impr ove MEP, another finding of the current study. Participant 1, who was not included in hyoid bone displacement measures made the most dramatic improvement in P A score from pre to post data co llection session. Participant 2 increased both vertical elevati on and anterior excursion of the hyoid bone, but did not show change in P A score from pre to post ICST. Participant 3 demonstrated slight increases in hyoid bone angle and magnitude of displacement and showed a similar mild improvement in P A s core. T his mild improvement may be due to the ceiling effect, as participant 3 displayed the mildest pre testing scores out of the three participants, indicating greater airway protection during pre testing (Rosenbek et al., 1996) Statistical analysis is needed in order to conclude the extent of p ositive correlation between P A scores and hyoid displacement measures within the current study Lastly, all participants either showed little change or worsened overall scores of the SWAL QOL questionnaire, thus refl ecting little change or worsening of perceived swallowing function and an increase in perceived swallowing problems. All participants showed pre testing scores reflecting mild moderately diminished swallowing related quality of life (McHorney et al. 2000 McHorney et al., 2006) When converting raw overall score using the Likert method to a linear metric scale of 0 100, percentage of

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57 change of the participants from pre to post testing may be co nsidered minimal, ranging between 0.5% to 8.9% change (Likert 1932). It is interesting that all thr ee participants scored very little change or lower in perceive d swallowing function, while two out of three of the participants demonstrated physiologic improvements to swallowing function either in P A score or hyoid bone displacement measures. This outcome, in addition to discrepancies observed in V RQOL scores, may be due to other factors not investigated by the current study, such as increased awarene ss of swallowing problems. Also, disease progression detr imentally affects the SWAL QOL scores, according to Leow, Huckabee, Anderson, and Beckert (2010). Another study, by Plowman Prine et al. (2009) found that swallowing specific quality of life was highly correlated with general health related quality of lif e and depression. Additionally this phenomenon could be partly attributed to sensory changes. Discrepancies in patient perception of swallowing function and actual physiologic changes to the swallowing mechanism are evidenced by the prevalence of subcli nical ph ysiologic changes in swallowing function in earlier stages of PD such as undetected piecemeal deglutition and smaller and more variable tongue movements (Potulska et al., 2003; Van Lieshout et al., 2011).

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58 CHAPTER 5 CONCLUSIONS AND FUTU RE RESEARCH T he results of this investigation indicate that a choral singing program, such as ICST, integrating both speech language ther apy and music therapy components may lead to positive changes in voice and swallowing measures for individuals with PD. As this pilot study utilized a small sample size, more research needs to be completed in order to determine the effectiveness and efficacy of ICST in improving voice and swallowing measures in individuals with PD. In the current study, data collection sessions were 2.5 3.0 hours in duration due to the recording of measures of speech and cognition not discussed in this paper. This long duration could have caused an e ffect of fatigue, waning concentration, and diminished motivation throughout the data collection session A future study investigating ICST should include measures of SPL, MEP, MPT, hyoid bone displacement and ang le measures, and P A scores due to the suggestive increases or improvements found in the current study. Measures of functi onal outcomes such as V RQOL and SWAL QOL as well as generalizatio n to daily speech tasks, such as outcomes of intelligibility during conversation or reading should be in cluded in a future study. These measures were included in the stu dy of MTVP by Haneishi (200 1), and yielded positive results. Furthermore, t he optimum duration, frequency, and procedure of home prac tice and singing sessions should be investigated. ICST singing sessions occurred once per week, with 2 3 hours of home practice, but other successful programs, namely LSVT, showed greatest change when clients were treate d more intensively at 4 therapy sessions per week (Spielmann et al., 2007). The VCST study

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59 by D i Ben edetto et al. (2009) also showed similar improvements to the current study but with a more intensive therapy program. Future ICST intervention s should also include more of a variety of songs for home practice, in order to keep participants high ly motivated and challenged. The effectiveness of the ICST home program could be investigated in isolation from the ICST singing sessions as participants showed high compliance of 100% a nd commonly individuals with PD experience mobility and transporta tion issues which prevent them from attending highly intensive therapy programs ( Uc et al., 2011;Spielman et al.,2007) The possible long term impact and outcomes of ICST should be investigated as well as the possible impact of using ICST in combination w i th a more established voice or swallowing therapy. C orrelations between age, sex, and duration of disea se from onset and outcomes should be analyzed. In a future study, the relationships between extent and dura tion of hyoid bone displacement, P A score, and UES opening should be investigated as positive results to these measures have been found from EMST (Troche et al., 2010) Finally, hyoid bone displacement and elevation should be measured under videoflurosco py during vocal exercise and singing employed during ICST s essions, in order to compare to hyoid bone movement during swallowing events.

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60 APPENDIX A VOICE MEASURE AND HYOID DISPLACEMENT CHANGE SCORE TABLES Table A 1 Ma ximum phonation time for /a/ ( in seconds ) from pre to post treatment Participant Number Pre CST Post CST Change Score 1 24 23 1.0* 2 13 34 21.0* 3 18 24 6.0* Table A 2. Maximum phonation time of /i/ ( in seconds ) from pre to post treatment Participant Number Pre CST Post CST Change Score 1 22 21 1.0* 2 18 26 8.0* 3 20 26 6.0* Table A 3 Maximum frequency range ( in semitones ) from pre to post treatment Participant Number Pre CST Post CST Change Score 1 28.28 36.74 8.46* 2 37.65 29.69 7.96* 3 35.42 31.84 3.58* Table A 4 Maximum sound pressure level ( in dB SPL ) Table A 5. Maximum expiratory pressure ( in cm H 2 0 ) from pre to post treatment Table A 6. Maximum inspiratory pressure ( in cm H 2 0 ) from pre to post treatment Participant Number Pre CST Post CST Change Score 1 80.33 90.33 10* 2 79.33 83.67 4.34* 3 97.33 103.67 6.34* Participant Number Pre CST Post CST Change Score 1 75 76 1* 2 54 63 9* 3 97.33 103.67 14* Participant Number Pre CST Post CST Change Score 1 80.33 71.67 8.66* 2 34 54 20.00* 3 62.33 59.33 3.00*

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61 Table A 7. V RQOL scores pre and post ICST Participant Number Pre CST Post CST Post CST descriptive score 1 12 13 good excellent* 2 17 13 good excellent* 3 15 18 fair good* Table A 8 Participant 2 average angle of elevation (in degrees) for thin liquid Measure Mean(Pre) Mean (Post) Change Score A1 4.04 8.60 4.56* A2 11.38 22.24 10.85* A3 11.08 21.64 10.57* Table A 9 Participant 2 average angle of elevation (in degrees) for pudding thick liquid Measure Mean(Pre) Mean (Post) Change Score A1 12.47 13.85 1.38* A2 14.68 14.73 0.05* A3 14.53 14.47 .06* Table A 10 Participant 3 average thin liquid angle of elevation (in degrees) Measure Mean(Pre) Mean (Post) Change Score A1 8.14 4.67 3.47* A2 14.61 11.78 2.83* A3 13.97 11.46 2.52* Table A 11 Participant 3 average pudding thick angle of elevation (in degrees) Measure Mean(Pre) Mean (Post) Change Score A1 7.47 10.60 3.13* A2 12.30 14.21 1.91* A3 11.92 13.88 1.96* Table A 12 Participant 2 average thin liquid magnitude displacement (in millimeters) Measure Mean(Pre) Mean (Post) Change Score D1 1.42 1.47 0.05* D2 1.07 1.23 0.15* D3 0.45 0.48 0.04* Table A 13 Participant 2 average pudding thick magnitude displacement (in millimeters) Measure Mean(Pre) Mean (Post) Change Score D1 1.43 1.48 0.05* D2 1.35 1.43 0.08* D3 0.43 0.52 0.09*

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62 Tab le A 14 Participant 3 magnitude displacement (in millimeters) for thin liquid barium swallows Measure Mean(Pre) Mean (Post) Change Score D1 1.35 1.35 0.001* D2 1.14 1.11 0.03* D3 0.39 0.36 0.02* Table A 15 Participant 3 magnitude displacement (in millimeters) for pudding thick barium swallows Measure Mean(Pre) Mean (Post) Change Score D1 1.36 1.29 0.07* D2 1.16 1.12 0.04* D3 0.34 0.30 0.04*

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63 APPENDIX B WEEKLY INTERVENTION SPL FIGURES Figure B 1. Weekly individual SPL during Messa di V oce exercises Figure B 2. Weekly individual SPL during choral s inging Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Participant 1 72 80 87 82 78 80 85 86 Participant 2 69 79 85 82 83 78 83 84 Participant 3 85 87 99 85 86 84 86 90 50 60 70 80 90 100 dB SPL Maximum Sound Pressure Level:Messa di Voce Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Participant 1 72 84.5 87 88.5 86 88 89 89.5 Participant 2 69 87.5 90 88.5 91.5 90.5 89.5 89.5 Participant 3 85 88.5 90 92 90.5 91.5 94 92 50 60 70 80 90 100 dB SPL Maximum Sound Pressure Level:Choral Singing

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72 BIOGRAPHICAL SKETCH Sarah Katherine Funderburke was born in Atlanta, GA to Janice and Danny Funderburke. She has one younger brother named Daniel. Sarah grew up in various cities across the Southeast ern United States, until her graduation from middle school, upon which her family settled and has rem ained in Merritt Island, FL. Sarah began her college career at UF as a vocal performance major with an interest in Pre Health. She sa ng in Mr. d the UF Concert Choir. After her first semeste r at UF, she decided to pursue s peech language pathology as her career and soon developed a passion for this subject that merged both her love of the voice and the medical sciences. Sarah graduated in Communicative Sciences and Disorders in 2010 and continued at UF in the Speech Languag e Pathology Master of A rts pro gram In this program, she has worked as a student in a variety of both adult and pediatric setting and has worked a s speech language pathology assistant part time. Her adult experiences include Voice Clinic in Shands Hospital in patient Speech and Language Services at S hands Hospital and the Center for Movement Disorders and Neurorestoration at the University of Florida in which her interests in voice, motor speech, and language disorders grew. She helpe d to treat children with cranio facial abn ormalities at the Shands C ranio f acial C linic and served as a camp counselor and student t herapist at a cranio facial camp. Lastly, she gained experience both as a student and an assistant wo rking with children 3 21 y ears of age with language delay, articulation, and pragmatic deficits. In the future, s he plans to become a certified medical speech language pathologist.