Effects of Deep Brain Stimulation (DBS) on Speech and Voice in Parkinson’s Disease ... · 2013. 3. 29. · 89% of PD patients as the disease progresses as well as speech abnormalities

143

This study was supported in part by the Catholic University of Daegu and Research Institute of Biomimetic Sersory Cortrol

Received January 19 2012 Final revision received February 29 2012 Accepted March 7 2012

2012 The Korean Academy of Speech-Language Pathology and Audiology httpwwwkasa1986orkr

Effects of Deep Brain Stimulation (DBS) on Speech and Voice in

Parkinsonrsquos Disease Acoustic Measures of Vowels from

Sustained Phonation and Running Speech Using Perturbation

and Nonlinear Dynamic Analysis

Seong Hee Choisect Department of Audiology and Speech-Language Pathology and Research Institute of Biomimetic Sensory Control College of Medical Sciences Catholic University of Daegu Kyungsan Korea

sect Correspondence to

Prof Seong Hee Choi PhD Department of Audiology and Speech-Language Pathology and Research Institute of Biomimetic Sensory ControlCollege of Medical Sciences Catholic University of Daegu5 Gumgokri Hayangup Kyungsansi Kyungsanbookdo Koreae-mail shgracecuackrtel +82 53 850 3841

Background amp Objectives Deep brain stimulation (DBS) of the thalamus or basal ganglia has been considered one of the most stable and long-term effective neurosurgical therapeutic inter-ventions for Parkinsonrsquos Disease (PD) Evidence of a surgical approach with DBS in PD with regardto voice and speech is still lacking The present study aims to investigate if nonlinear dynamic analysis with vowels from sustained phonation and running speech can be used to investigate the effects of electrode implantation and stimulation of the thalamic nucleus (STN) on patientsrsquovoice and speech in advanced stages of PD Methods Nineteen idiopathic PD patients that received DBS-STN surgery and ten idiopathic PD patients that did not receive DBS-STN surgeryparticipated in the present study Participants did not receive medication for 12 hours overnightprior to the recording session For surgical patients recordings were taken with the stimulator on (for at least 12 hours) and off (for 30 minutes) The sustained and running vowel segments were used to analyze the perturbation including percent jitter shimmer signal-to-noise ratio (SNR) values and nonlinear dynamic method of correlation dimension (D2) Results Results showed that the mean D2 value of the surgical group was significantly lower than the mean D2value of the non-surgical group for sustained and running vowels The perturbation results failed to achieve significance with DBS contradicting the results of nonlinear dynamic analysisDiscussion amp Conclusion Nonlinear dynamic analysis showed effects of DBS on PD patientsrsquovoice and speech and may be a useful substitute for perturbation analysis in the evaluation of running speech because of the short signal length and high noise level The results indicate thatnonlinear dynamic analysis may be useful to evaluate the treatment effect in PD patients with severe voice and speech disorders (Korean Journal of Communication Disorders 201217143-155)

Key words Deep Brain Stimulation (DBS) Parkinsonrsquos speech and voice nonlinear dynamic analysis perturbation analysis sustained phonation running speech

Ⅰ Introduction

Parkinsonrsquos disease (PD) is progressive neuromus-

cular disorder (Kim Kearney amp Atkins 2002) The

Characteristic movements of abnormalities such as

resting tremor rigidity bradykinesia and postural

abnormalities observed in PD are caused by dopamine

deficiency associated with degeneration of the

substantia nigra (Marsden 1994) Laryngeal dys-

function or experience voice difficulties were reported

89 of PD patients as the disease progresses as

well as speech abnormalities (Hanson Gerratt amp

Ward 1984) It is of significant clinical interest to

reduce voice and speech symptoms and explore

the suitable treatment option for PD patients The

common deficit in speech and voice is lsquohypokinetic

Korean Journal of Communication Disorders 201217143-155

144

dysarthriarsquo and its typical characteristics include

abnormal prosody variability in speech rate im-

precise movements of the articulators reduced

loudness monotone breathiness and harsh voice

(Hanson Gerratt amp Ward 1984 Gentil amp Pollak

1995 Ramig et al 1995 Sewall Jiang amp Ford

2006) Laryngeal tremor was observed early in the

Parkinsonrsquos disease patients (Perez et al 1996) and

the major laryngeal abnormalities in advanced PD

patients are prominent vocal fold bowing with glottal

incompetence (Blumin Pcolinsky amp Atkins 2004)

hypophonia (Hartelius amp Svensson 1994 Liotti et

al 2003) and abnormal phase closure and phase

asymmetry (Perez et al 1996)

Several studies on PD speech and voice treatment

including pharmacological treatment such as le-

vodopa (Rascol et al 1994 Sanabria et al 2001

Pahwa 2006) neurosurgery such as stereotactic

pallidotomy (Schulz et al1999 Schulz amp Grant

2000) laryngoplasty for vocal folds medialization

(Sewall Jiang amp Ford 2006) have been attempted

to investigate treatment efficacy of parkinsonrsquos re-

lated dysphoinia and dysarthria Although some

results demonstrated clinically significant efficacy

treatment outcomes were limited to small samples

of PD short-term effect or different depended on

different level of dysarthria severity Additionally

levodopa has been used widely to treat symptoms

of PD but the drug side effects including dystonia

and dyskinesia were reported (Parkin et al 2002)

Recently deep brain stimulation (DBS) of the

thalamus or basal ganglia has been considered one

of the most stable and long-term effective neuro-

surgical therapeutic intervention which significantly

improves all areas of limb motor performance such

as rigidity tremor and akinesia (Benabid 2003

Burchiel et al 1999 Iansek Rosenfeld amp Huxham

2002 Krack et al 2003 Kumar amp Mullick 1996

Limousin et al 1998 Xie et al 2001) and preferred

treatment method for patients with advanced PD

due to improvement of the major symptoms of the

disease more effectively than globus pallidus stim-

ulation (Wang et al 2003) The effect of DBS on

speech and voice however has yielded inconsistent

outcomes

Multiple preliminary studies have shown that

DBS of the subthalamic nucleus (STN) improved

maximal phonation time vocal intensity level and

fundamental frequency variability (Gentil et al

2001 Gentil et al 2003 Hoffman-Ruddy et al

2001) In contrast Farrell et al (2005) found that

individuals with PD who had surgery including

thalamotomy pallidotomy or DBS exhibited an im-

proved Hoehn amp Yahr stage of PD score compared

to a non-surgery PD group whereas there were no

significant changes in speech for surgical PD group

Likewise Wang et al (2003) reported subthalamic

nucleus had some positive effects or no changes in

speech and the recent study by Dromey amp Bjarnason

(2011) displayed that articulation (corner vowel

formants diphthong slopes) and phonation (per-

turbation long-term average spectrum) outcomes

showed some speakers improved while others

became worse but only 6 PD with DBS were par-

ticipated in this study Additionally some studies

revealed the DBS effects on speech deteriorated

(Gentil et al 2003 Toumlrnqvist Schaleacuten amp Rehncrona

2005) Sung et al (2004) evaluated maximum

phonation time (MPT) jitter (pitch perturbation)

shimmer (intensity perturbation)tremor indices

and diadochokinetic rate (DDK) to investigate the

effects of DBS with bilateral STN on the phonation

and articulation of 7 PD with levodopa lsquoonrsquo and lsquooffrsquo

treatments They found no significant changes in

the DDK rate under any condition at the articulatory

level and only percent shimmer values decreased

when the patients were levodopa lsquooffrsquo while both

the DBS and levodopa treatment caused significant

prolongation of the MPT suggesting STN DBS

improved phonation but had limited effects on

articulation in individuals with PD in advanced

stage

Acoustic perturbation measures have been com-

monly used as an objective method for evaluation

and diagnose of pathologic voice quality Percent

jitter and shimmer as well as harmonic to noise

ratio (HNR) have traditionally been used to describe

voice quality On the other hand some studies have

cautioned against applying of perturbation acoustic

analysis to severely impared pathologic voice which

Choi Effects of Deep Brain Stimulation (DBS) on Speech and Voice in Parkinsonrsquos Disease

145

are presented in voice of some PD patients (Titze

1995 Karnell et al 1997 Yiu 1999) In addition

some hypophonic PD voices cannot be analyzed by

using some commercialized voice analysis system

Non-linear dynamic analysis methods (eg Phase

space reconstruction and correlation dimension

(D2) as complement of perturbation analysis have

been employed broadly to quantify highly aperiodic

and chaotic pathologic voice signals including

speakers with vocal polyps parkinsonrsquos voice

unilateral vocal fold paralysis muscle tension

dysphonia esophageal voice as well as pediatric

dysphonia (Awan Roy amp Jiang 2010 MacCallum

et al 2009 Meredith et al 2008 Rahn et al 2007

Zhang et al 2004 2005a Zhang Jiang amp Rahn

2005) Thus nonlinear dynamic approach can be

applied to quantify aperiodic and chaotic laryngeal

activity and give reliable outcomes to clinician to

assess treatment effects of laryngeal pathologies

Zhang Jiang amp Rahn (2005) studied to theoretical

nonlinear model for identifying vocal fold vibrations

in Parkinsonrsquos disease and pathologic vocal

characteristics including reduced vibratory intensity

incomplete vocal closure increased phonation

threshold pressure glottal tremor subharmonics

and chaotic vocal fold vibration are suitable to apply

to the nonlinear analysis model Similarly Rahn et

al (2007) used non-linear analysis with voices of

PD patients and normal with sustained phonation

The results showed PD subjects have significantly

higher D2 values than control subjects (p = 0016)

which indicates increased signal complexity in PD

vocal pathology Differences in the comparison of

two groups were significant in jitter (p = 0014) but

no significant in shimmer (p = 0695) In addition

Choi (2011) used nonlinear analysis of PD voices

with sustained vowel to test the effect of LSVTreg

(Lee Silverman Voice Treatment) and found signifi-

cantly lower percent jitter and D2 values in LSVTreg

group compared to non- LSVTreg group

Sustained vowels only could be used in most

commercialized voice analysis systems and simple

methods to evaluate in the clinical setting because

sustained vowels are obtained in more clearly con-

trolled environment related to aspects of voice

source vocal tract and relatively devoid of individual

speech characteristics such as speaking rate speakerrsquos

dialect intonation and articulatory behavior (Parsa

amp Zamieson 2001) In contrast running speech

involves dynamic and rapid adjustment of vocal

mechanisms which is important indicator of vocal

quality Even though running speech is natural

and reflect day-to-day speech Parsa amp Zamieson

(2001) noted that careful selection of the region of

fo contour for valid of perturbation was needed

when extracting perturbation analysis from running

speech According to Zhang amp Jiang (2008) nonlinear

dynamic analysis such as correlation dimension

(D2) allows a more stable analysis with shorter signal

lengths such as extracting vowels from running

speech and lower sampling rates and high noise

level It is hypothesized that some prior studies

might represent weak or no significant DBS effect

on PD voice and speech since the utility of some

commercialized voice analysis system may not be

suitable or reliable to analyze severe PD voice in

advanced stages and analysis of running speech might

also give better understanding of the DBS effects than

that of sustained vowels The objective of this study

therefore is to investigate the effects of implan-

tation of electrode and stimulation of the thalamic

nucleus (STN) on parkinsonrsquos voice and speech with

both perturbation and non-linear analysis using both

sustained phonation and running speech

Ⅱ Method

1 Participants

The protocol and consent procedure was approved

by the University of Wisconsin Institutional Review

Board and the Committee of Ethics at Shanghai

Second Military Medical University Hospital All

participants were Chinese An attending neurologist

recruited 19 idiopathic PD patients 11 males and

8 females with an average age of 638 years that

received DBS-STN surgery ltTable- 1gt and 10 idi-

opathic PD patients 6 females and 4 males with a

mean age of 668 years that did not receive DBS-


146

Patient Gender Age Hoehn-Yahr Side of STN UPDRSa)-ⅢUPDRS-ⅢItem 18 (Speech)

Perceptual Ratingb) (General Vocal

Impairment)

PD Duration

1 Female 68 Ⅲ Bilateral 51 0 3 12


3 Male 67 Ⅳ Bilateral 108 2 3 14

4 Male 61 Ⅲ Left 51 0 4 18

5 Male 50 Ⅲ Bilateral 78 1 4 5




9 Female 57 Ⅴ Left 100 2 4 11

10 Male 72 Ⅲ Left 67 1 4 6

11 Male 76 Ⅲ Left 80 1 3 13

12 Male 63 Ⅲ Left 62 1 5 8

13 Male 58 Ⅳ Left 84 1 5 10


15 Female 48 Ⅲ Left 62 0 2 10

16 Female 66 Ⅲ Right 65 0 4 7


18 Female 68 Ⅳ Bilateral 78 1 3 10

19 Male 69 Ⅲ Right 62 1 4 6

MeanSD

NA63877

332(Ⅲ=3

Ⅳ=4 Ⅴ=5)

7142153

07406

3610

93235

a) UPDRS Unified Parkinsonrsquos Disease Rating Scaleb) Perceptual ratings (5-point equal appearing interval (EAI) rating scale 1 normal 5 largest deviation from normal)

ltTable-1gt Demographics and clinical characteristics in DBS surgical PD group

STN surgery ltTable-2gt The surgical and non-

surgical patients were selected for consistency in

the criteria shown in Tables 1 and 2 Three speech-

language pathologists with clinical specialization

in PD voice disorders (3-5 years) rated overall voice

quality for all vowel samples using a five-point equal-

appearing-interval (EAI) rating scale (1 normal 5

largest deviation from normal) The surgical pro-

cedure was identical to that discussed in Benabid

(2003) and the decision to undergo DBS-STN surgery

was made independent from the interests of this

study Participants did not have vocal deficits caused

by diseases other than PD symptoms outside of

those common to PD as detected by laryngeal endos-

copy cognitive hearing impairment or depression

T-test was used to compare the differences regarding

age Unified Parkinsonrsquos Disease Rating Scale (UPDRS)

for speech stage of disease (Hoehn amp Yahr 1967)

between surgical and non-surgical groups ltTable

-3gt and no significant differences were found for

any of the variables between groups in the baseline

of this study (p gt 05)


147

Patient Gender Age Hoehn-Yahr UPDRSa)-Ⅲ UPDRS-ⅢItem 18(Speech)

Perceptual Rating(General Vocal

Impairment)

PD Duration Since

Diagnosis (years)

1 Female 74 Ⅲ 88 1 3 2

2 Female 74 Ⅳ 100 2 5 5

3 Female 73 Ⅲ 76 1 2 3

4 Female 59 Ⅳ 94 1 3 7

5 Female 57 Ⅲ 64 0 1 6

6 Female 77 Ⅲ 68 0 4 lt1

7 Male 61 Ⅳ 96 1 4 9

8 Male 68 Ⅲ 72 1 4 4

9 Male 49 Ⅲ 62 0 3 2

10 Male 76 Ⅳ 86 2 4 4

MeanSD

NA66897

34(Ⅲ=3

Ⅳ=4 Ⅴ=5)

806139

0907

3311

4226

a) UPDRS Unified Parkinsonrsquos Disease Rating Scale

ltTable-2gt Demographics and clinical characteristics in non-surgical PD group

ltTable-3gt Mean (SD) values of demographics and clinical characteristics for surgical and non-surgical PD group

Surgical PD

(N=19)

Non-surgical

PD (N=10)p-Value

Age(yr) 638(77) 668(97) p gt 005

UPDRSa)

(speech)074(06) 09(07) p gt 005

H amp Yb) 332(06) 34(07) p gt 005

Perceptual

rating36(10) 34(11) p gt 005

a) UPDRS = Unified Parkinsonrsquos Disease Rating Scale b) H amp Y = Hoehn amp Yahr stage

2 Recording Procedure

Participants did not receive medication for 12

hours overnight prior to the recording session

(medication-off condition) For surgical patients

recordings were taken with the stimulator-on (for

at least 12 hours) The stimulator-off recordings

however were not reported because of the short

duration of the stimulator-off period which was the

longest the patients were able to tolerate For non-

surgical patients recordings were taken once

In each session sustained a vowel phonations

of no less than 5 seconds and a vowel from running

speech by reading a sentence in Mandarin Chinese

were recorded in a sound-attenuated room using a

head-mounted microphone (AKG Acoustics Vienna

Austria) positioned at 15 cm from the mouth at a

45 degree angle Audio files were recorded at a

sampling rate of 25 kHz using Multispeech software

(Kay Elemetrics Corporation Lincoln Park NJ)

Patients were directed to perform sustained phona-

tion and running speech within their normal vocal

range For the sustained phonations relatively more

stable 3 replicate recordings were selected for an-

alysis from 5 replicates and 1-second segments were

cut to eliminate the offset and onset of phonation

For running speech 2 replicate recordings from 3

replicates were taken for analysis and the running

vowel a was selected to eliminate the effects of

fricative and silence segments Each running vowel

segment with a minimum length of 100 ms was cut

to eliminate the offset and onset of voice Both sus-

tained and running vowel segments were processed

using perturbation and nonlinear dynamic analysis

The research assistant that directed the patient


148

was blind to the patient group for the first set of

recordings and the stimulator condition The patient

was blind to the stimulator condition Therefore

data collection satisfied double blindness Another

research assistant blind to the patient group and

stimulator condition analyzed the data achieving

blindness at this stage of data processing

3 Data Analysis

CSpeech 40 software (Paul Milenkovic Madison

Wisconsin) was used to obtain percent jitter percent

shimmer and signal-to-noise ratio (SNR) values for

both sustained and running vowel segments CSpeech

was also used to calculate err the number of counts

the algorithm failed to extract a pitch period for all

patients (Milenkovic amp Read 1992) An error greater

than 10 indicated an unreliable pitch period The

waveforms of the segments with err values greater

than 10 had type 2 (bifurcations and modulations

evident) or type 3 (aperiodic and chaotic) signals

Previous studies have shown that perturbation

analysis is only reliable for nearly periodic voice

samples and therefore perturbation results for these

segments were eliminated (Titze 1995) The non-

linear dynamic method of correlation dimension

(D2) which studies have shown does not have the

periodicity requirement that limits perturbation

methods was also used to analyze sustained and

running vowel segments The theory usage and

determination of correlation dimension calculations

have been described extensively in previous studies

(Herzel et al 1994 Jiang Zhang amp Ford 2003

Jiang Zhang amp McGilligan 2006 Kumar amp Mullick

1996 Narayanan amp Alwan 1995 Titze Baken amp

Herzel 1993 Zhang et al 2004 Zhang et al 2005a

2005b Zhang Jiang amp Rahn 2005) Compared to

perturbation methods nonlinear dynamic analysis

such as correlation dimension (D2) do not require

determination of a pitch period which is a compon-

ent of the algorithms used in perturbation analysis

Briefly ltFigure-1gt shows a phonatory time series

χ(ti) ti = t0 +iΔt (i = 12hellipN) from a surgical patient

sampled at Δt = 1ƒs The time length analyzed is 1 s

(figures were magnified) (N=25000) The recon-

structed phase space shown in ltFigure-2gt plots

the voice signal against itself at a time delay τ calcu-

lated by Fraser and Swinneyrsquos mutual information

method (1986) Correlation dimension (D2) measures

the correlation of any two points in this phase space

or the complexity and irregularity of this phase

space Higher correlation dimension indicates higher

aperiodic vocal pathology and a more severely

impaired Parkinsonian voice a zero-dimensional

fixed point(static states) a one-dimensional limit

cycle(periodic oscillations) a two-dimensional quasi-

periodic torus(superposition of two or more oscil-

lations) or a fractal dimensional chaotic trajectory

(apeirodic oscillations (Herzel et al 1994 Jiang

Zhang amp McGilligan 2006) Grassberger and

Procacciarsquos correlation dimension (1983) was calcu-

lated based on the definition rrCD

r log)(loglim

02 rarr=

where r is the radius around Ⅹ i and

sum summinus

=

minusminus

=+minusminus

minusminus+=

1 1

0||)||(

))(1(2)(

N

Wn

nN

iniir

WNWNrNWC XXθ

was calculated using Theilerrsquos formula (1986) W

was set as the time delay τ and θ (χ) satisfies

⎩⎨⎧

legt

=0001

)(xx

xθ The correlation dimension is obtained

with a linear curve fit to D2 vs r in the scaling region

where the slopes of these two curves increase

transiently and then converge as embedding dimen-

sion m is increased ltFigure-3gt shows the curves

D2 vs r from the same surgical patient as shown in

ltFigure-1gt The slopes of the D2 vs r curves approach

3038 plusmn 0004 in the indicated scaling region which

is the estimated D2 of this voice Using the steps

outlined above correlation dimension values were

obtained for all vowel segments


149

Non

-surgical

group

Surgical

groupp-Value

Sustained

vowel

Percent

jitter

0405

(plusmn0318)

0563

(plusmn0433)01741

Percent

shimmer

6200

(plusmn3169)

6498

(plusmn3550)07393

SNR15336

(plusmn5165)

14407

(plusmn4875)04253

D23585

(plusmn0772)

2648

(plusmn0828)lt 00001

Running

vowel

Percent

jitter

0851

(plusmn0509)

1108

(plusmn0743)02688

Percent

shimmer

7953

(plusmn4197)

9011

(plusmn4274)03741

SNR12016

(plusmn3758)

13500

(plusmn3385)01291

D24076

(plusmn0990)

3012

(plusmn1340)00002

ltTable-4gt Mean (SD) values of percent jitter percent shimmer SNR and D2 for vowels from sustained phonation and running speech between the non-surgical and surgical PD groups

ltFigure - 1gt A waveform in DBS-STN surgical PD group

ltFigure - 2gt A reconstructed phase space in non-surgical PD group

It represents the dynamic behavior of one PD voice signal with no surgery showing aperiodic voice signal which looks irregular and chaotic not closed trajectory

in phase space

ltFigure - 3gt The curves D2 vs r from the same surgical patient as shown in ltFigure - 1gt The slopes of the D2 vs

r curves approach 3038 plusmn 0004 in the indicated scaling region

which is the estimated D2 of the voice signal

4 Statistical Analysis

Means were calculated for each of 4 measures

(percent jitter percent shimmer SNR D2) for sus-

tained and running vowel segments of non-surgical

patients and surgical patients A Mann-Whitney rank

sum test was used to test for differences between the

non-surgical and surgical patients Statistical p-values

less than 005 were considered significant Statistical

computations were run on SigmaStat 20 (Jandel

Scientific San Rafael CA) software and graphs

generated using SigmaPlot 40 (Jandel Scientific)

software

Ⅲ Results

ltTable-4gt shows mean percent jitter shimmer

SNR and D2 values of sustained and running vowel

segments for the non-surgical and surgical groups

ltFigure-4 gt through ltFigure-7gt displays boxplots

of percent jitter shimmer SNR and D2 values from

sustained and running vowel segments for each

group


150

ltFigure - 4gt Percent Jitter for the non-surgical and surgical group with sustained and running vowels

ltFigure - 5gt Percent Shimmer for the non-surgical and surgical group with sustained and running vowels

ltFigure - 7gt D2 for the non-surgical and surgical group with sustained and running vowels

ltFigure - 6gt SNR for the non-surgical and surgical group with sustained and running vowels

For sustained vowels the mean percent jitter and

shimmer values were 0405 and 6200 respectively

for the non-surgical and surgical group and 0563

and 6498 respectively for the surgical group As

shown in ltTable-4gt mean percent jitter and shimmer

were higher in the surgical group than non-surgical

group but this difference was not significant (p =

1741 p = 7393) For running vowels the mean

percent jitter and shimmer values were 0851 and

7953 respectively for the non-surgical group and

1108 and 9011 respectively for the surgical group

As with sustained vowels percent jitter and shim-

mer were higher in the surgical group than non-

surgical group but this difference was not significant

(p = 2688 p = 3741)

For sustained vowels mean SNR values were for

the non-surgical and surgical groups were 15336

and 14 407 respectively For running vowels the

mean of SNR values for the non-surgical and surgical

group were 12016 and 13500 respectively Mean

SNR values were neither significantly lower for

sustained vowels (p = 4253) nor significantly higher

for running vowels in the surgical group (p = 1291)

For sustained vowels mean D2 values for the non-

surgical and surgical groups were 3585 and 2648

respectively The mean D2 value of the surgical group

was significantly lower than the mean D2 value of

the non-surgical group (p lt 0001) For running

vowels mean D2 values for the non-surgical and

surgical groups were 4076 and 3012 respectively

As with sustained vowels the mean D2 value of the

surgical group was significantly lower than the mean

D2 value of the non-surgical group (p lt 0002)

IV Discussion and Conclusion

The current study attempted to extend the measures

vowels from sustained phonation to running speech


151

to explore the effect of DBS on treatment of PD speech

and voice with acoustic measures under levodopa

lsquooffrsquo condition with advanced PD patients who

exhibited more than Hoehn amp Yahr stage Ⅲ

The symptoms of speech and voice dysfunction

in PD (hypokinetic dysarthria) are weak voice vari-

able speech rate short rushes of speech imprecise

consonants breathy and harsh voice and monoto-

nous pitch Effects of STN-DBS on speech and voice

motor function are less well defined and have been

reported either as variable (Dromey et al 2000

Hoffman et al 2001 Gentil et al 2003 Murdoch

2010) or as an adverse side effect of the stimulation

(Deuschl et al 2006)

Farrell et al (2005) found that neurosurgical inter-

vention including the procedures of pallidotomy

thalamotomy and deep-brain stimulation (DBS)

did not significantly change the 22 surgical partici-

pantsrsquo perceptual voice and speech dimensions

including reduced vocal intensity reduced vocal

pitch monopitch monoloudness imprecise articu-

lation and oromotor function despite significant

postoperative improvements in ratings of general

motor function and disease severity

In addition Dromey et al (2000) measured the

acoustic recordings and neurologic assessments with

7 PD patients who were implanted with deep brain

stimulators and found significant improvements in

limb motor performance when the subthalamic

nucleus was stimulated following surgery Although

there was small significant increases in sound pres-

sure level and fundamental frequency variability in

response to stimulation in the medication-on con-

dition while no significant speech changes were

found Another study revealed that reaction and

movement time of the articulatory organs decreased

and their maximal strength and articulatory precision

as well as voice function significantly improved (Gentil

et al 2003) Most recently a preliminary study for

measuring DBS effect on voice and speech with 6PD

demonstrated only 2PD with DBS improved percent

jitter shimmer following stimulation on while most

PD with DBS (4PD) became worse by increasing

percent jitter and shimmer values and represented

variable outcomes in speech intelligibility with vowel

space area and smaller formant transitions reflecting

poorer perceived speech (Dromey amp Bjarnason

2011)

Recently most of the aperiodic voice signals and

severe dysphonia as well as periodic voice signals so

far have been successfully quantified with nonlinear

dynamic approach Nonlinear dynamic methods

including reconstructed phase space and correlation

dimension (D2) have been considered as new acous-

tic methods to describe aperiodic and chaotic activities

and can predict period-doublings bifurcations de-

terministic chaotic or nonlinear dynamic system

rather than stochastic chaos (Titze et al 1993 Zhang

et al 2005a 2005b Zhang Jiang amp Rahn 2005)

Typically sustained vowels are much more commonly

used in acoustic measures because they can be

obtained in a more easily controlled environment

reducing variances in acoustic parameters Further-

more sustained vowels do not vary with dialect

intonation and articulation of the speaker which

may affect the acoustic results (Zhang amp Jiang 2008)

Running speech however exhibits the dynamic

natural phonation characteristics of everyday speech

whereas sustained vowels are more characteristic

of singing (Klingholtz 1990 Parsa amp Jamieson

2001) In addition running speech has variations in

pitch and loudness which are important properties

when assessing the effectiveness of treatments on

PD voice and speech (Askenfelt amp Hammarberg

1986) The present study showed mean D2 value of

the surgical group was significantly lower than the

mean D2 value of the non-surgical group for both

sustained and running vowels indicating an im-

provement in sustained phonation and running

speech with DBS Our initial study has reported

aperiodicity improvement in sustained vowel pho-

nation in PD patients with DBS (Lee et al 2008)

Many PD vocal samples in this study have type 2

signals containing subharmonics or even type 3

signals making the D2 results more reliable and

nonlinear dynamic method may provide measurable

improvement in patients with severe vocal impair-

ment For sustained phonations the improvement

in D2 may be associated with a decrease in vocal fold

rigidity and stiffness a common vocal symptom of


152

PD The contribution of current study is an analogous

finding for running speech As a result the impro-

vement in running speech in PD patients with DBS

found in this study may serve as a useful starting

point for further studies on the investigation of the

effects of DBS on PD speech

In the present study perturbation results fail to

achieve significance with DBS contradicting the re-

sults of nonlinear dynamic analysis Previous studies

have shown that nonlinear dynamic analysis may

be more reliable because of the aperiodicity asso-

ciated with PD voice and speech (Choi 2011 Rahn

et al 2007) In addition analysis of running speech

is more challenging for acoustic analysis in general

but poses additional difficulties for acoustic per-

turbation analysis Perturbation measures may not

be able to discriminate between variations inherent

in running speech and variations associated with

PD Furthermore running vowels have very short

signal lengths As a result running vowel segments

may not contain the requisite number of cycles for

stable and convergent perturbation measures Cor-

relation dimension (D2) however is reliable for the

shorter signal length and higher noise levels charac-

teristic of running speech and severe dysphonic

voice (Zhang amp Jiang 2008) Although a few studies

have applied nonlinear dynamic analysis to running

speech this study goes one step further by using

nonlinear dynamic analysis to evaluate treatment

effects on running speech The current study may not

address the specific speech characteristics of common

hypokinetic PD speech dimensions However the

perturbation and nonlinear dynamic analysis using

vowels from the running speech in addition to sus-

tained phonation might be a new attempt to reflect the

various speech characteristics including intonation

and articulation of PD speaker rather than PD speech

itself There were some limitations in this study First

although carefully selected to be as consistent as

possible the non-surgical group was composed of

different individuals (in terms of years since onset)

However there were no differences between two

groups in other parameters including age H amp Y

stage and UPDRS Second the small sample size

might be also limited the conclusions of this study

Third the sides of STN in surgical group were het-

erogeneous (eg left right bilateral) Future study

could investigate the effects of DBS treatment re-

garding this factor In addition the evaluation of

running speech should be viewed as a complement

to rather than substitute for the evaluation of sustained

phonation Nevertheless the findings of this study

show nonlinear dynamic analysis may be useful

substitute for perturbation analysis in the evaluation

of running speech because of the short signal length

and high noise level The current study extends the

use of nonlinear dynamic analysis of running speech

to the effects of DBS on PD voice and speech There-

fore this indicates the possibility of clinical application

of running speech as well as sustained vowels based

on nonlinear dynamic methods in investigating

treatment effects

This study was supported in part by the Catholic

University of Daegu and Research Institute of Bio-

mimetic Sensory Control and the author would like

to thank Jack J Jiang MD PhD to support this

research in laryngeal physiology lab Department of

Surgery Division of Otolaryngology University of

Wisconsin-Madison

REFERENCES

Askenfelt A G amp Hammarberg B (1986) Speech waveform perturbation analysis A perceptual-Acoustical com-parison of seven measures Journal of Speech and Hearing Research 29(1) 50-64

Awan S N Roy N amp Jiang J J (2010) Nonlinear dynamic analysis of disordered voice The relationship between the correlation dimension (D2) and pre-post-treatment change in perceived dysphonia severity Journal of Voice 24(3) 285-293

Benabid A L (2003) Deep brain stimulation for Parkinsonrsquos disease Current Opinion in Neurobiology 13(6) 695-706

Blumin J H Pcolinsky D E amp Atkins J P (2004) Laryngeal findings in advanced Parkinsonrsquos disease Annal Otolaryngology Rhinology Laryngology 113(4) 253-258

Burchiel K J Anderson V C Favre J amp Hammerstad J P (1999) Comparison of pallidal and subthalamic nucleus deep brain stimulation for advanced Parkinsonrsquos disease Results of a randomized blinded pilot study Neurosurgery 45(6) 1375-1382


153

Choi SH (2011) The effect of Lee Silverman Voice Treat-ment (LSVTreg) on Parkinsonian phonation Nonlinear dynamic perturbation and perceptual analysis Korean Journal of Communication Disorders 16(3) 335-345

Deuschl G Herzog J Kleiner-Fisman G Kubu C Lozano A M Lyons K E Rodriguez-Oroz M C Tamma F Troumlster A I Vitek J L Volkmann J amp Voon V(2006) Deep brain stimulation Postoperative issues Movement Disorders 21(14) S219-237

Dromey C Kumar R Lang A amp Lozano A (2000) An investigation of the effects of subthalamic nucleus stimulation on acoustic measures of voice Movement Disorders 15 1132-1138

Dromey C amp Bjarnason S (In press) A preliminary report on disordered speech with deep brain stimulation in individuals with Parkinsonrsquos disease Parkinsonrsquos Disease

Farrell A Theodoros D Ward E Hall B amp Silburn P (2005) Effects of neurosurgical management of Parkinsonrsquos disease on speech characteristics and oromotor function Journal of Speech Language and Hearing Research 48(1) 5-20

Fraser A M Swinnery H L (1986) Independent coordinates for strange attractors from mutual informations Phy-sical Review A 33 1134-1140

Grassberger P amp Procaccia I(1983) Measuring the strange-ness of strange attractors Physica D Nonlinear phe-nomena 9 189-208

Gentil M amp Pollak P (1995) Some aspects of Parkinsonian dysarthria Journal of Medical Speech-Language Pathology 3(4) 221-237

Gentil M Chauvin P Pinto S Pollak P amp Benabid A L (2001) Effect of bilateral stimulation of the subthalamic nucleus on Parkinsonian voice Brain and Language 78 233-240

Gentil M Pinto S Pollack P amp Benabid A L (2003) Effect of bilateral stimulation of the subthalamic nucleus on Parkinsonian dysarthria Brain and Language 85 190-196

Hanson D B Gerratt B R amp Ward P H (1984) Cinegraphic observations of laryngeal function in Parkinsonrsquos disease Laryngoscope 94 348-353

Hartelius L amp Svensson P (1994) Speech and swallowing symptoms associated with Parkinsonrsquos disease and mul-tiple sclerosis A survey Folia Phoniatrica et Lagopaedica 46 9-17

Herzel H (1993) Bifurcations and chaos in voice signals Applied Mechanics Reviews 46 399-413

Herzel H Berry D Titze I R amp Saleh M (1994) Analysis of vocal disorders with methods from nonlinear dynamic analysis Journal of Speech and Hearing Research 37 1008-1019

Hoffman-Ruddy B Schulz G Vitek J amp Evatt M (2001) A preliminary study of the effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on voice and speech characteristics in Parkinsonrsquos Disease (PD) Clinical Linguistics and Phonetics 15 97-101

Hoehn M M amp Yahr M D (1967) Parkinsonism Onset progression and mortality Neurology 17 427-433

Iansek R Rosenfeld J V amp Huxham F E (2002) Deep brain stimulation of the subthalamic nucleus in Parkinsonrsquos disease The Medical Journal of Australia 177(3) 142-146

Jiang J J Zhang Y amp Ford C N (2003) Nonlinear dynamics of phonations in excised larynx experiments Journal of the Acoustical Society of America 114 2198-2205

Jiang J J Zhang Y amp McGilligan C (2006) Chaos in voice from modeling to measurement Journal of Voice 20 2-17

Karnell M P Chang A Smith A amp Hoffman H (1997) Impact of signal type on validity of voice perturbation measures NCVS Status and Progress Report 11 91-94

Klingholz F (1990) Acoustic recognition of voice disorders A comparative study of running speech versus sustained vowels Journal of the Acoustical Society of America 87 2218-2224

Kim S H Kearney J J amp Atkins J P (2002) Percutaneous laryngeal collagen augmentation for treatment of Parkinsonian hypophonia Otolaryngol Head and Neck Surgery 126 653-656

Krack P Batir A Van Blercom N Chabardes S Fraix V Ardouin C Koudsie A Limousin P D Benazzoua A LeBask J F Benabid A amp Pollak P (2003) Five- year follow-up of bilateral stimulation of the subthalamic nucleus in advan ced Parkinsonrsquos disease The New England Journal of Medicine 349 1925-1934

Kumar A amp Mullick S K (1996) Nonlinear dynamical analysis of speech Journal of the Acoustical Society of America 100 615-629

Lee V S Zhou X P Rahn D A 3rd Wang E Q amp Jiang J J (2008) Perturbation and nonlinear dynamic analysis of acoustic phonatory signal in Parkinsonian patients receiving deep brain stimulation Journal of Communication Disorders 41(6) 485-500

Limousin P Krack P Pollak P Benazzouz A Ardouin C Hoffmann D amp Benabid A L (1998) Electrical stimulation of the subthalamic nucleus in advanced Parkinsonrsquos disease The New England Journal of Medicine 339(16) 1105-1111

Liotti M Ramig L O Vogel D Liotti M Ramig L O Vogel D New P Cook C I Ingham R J Ingham J C amp Fox P T (2003) Hypophonia in parkinsonrsquos disease Neural correlates of voice treatment revealed by PET Neurology 60(3) 432-440

Marsden C D (1994) Parkinsonrsquos disease Journal of Neuronal Neurosurgery Psychiatry 57 672-681

MacCallum J K Cai L Zhou L zhang Y amp Jiang J J (2009) Acoustic analysis of aperiodic voice Perturb-ation and nonlinear dynamic properties in esophageal phonation Journal of Voice 23(3) 283-290

Meredith M L Theis S M McMurray J S Zhang Y amp Jiang J J (2008) Describing pediatric dysphonia with nonlinear dynamic parameters International Journal


154

of Pediatric Otorhinolaryngology 72(12) 1829-1836

Milenkovic P amp Read C (1992) CSpeech Version 4 Userrsquos Manual Madison WI University of Wisconsin-Madison

Murdoch B E (2010) Surgical approaches to treatment of Parkinsonrsquos disease Implications for speech function International Journal of Speech-Language Pathology 12(5) 375-384

Narayanan S S amp Alwan A A (1995) A nonlinear dy-namical systems analysis of fricative consonants Journal of the Acoustical Society of America 97 2511-2524

Parkin S G Gregory R Scott R Brain P Silburn P Hall B Boyle R Joint C amp Aziz T Z(2002) Unilateral and bilateral pallidotomy for idiopathic Parkinsonrsquos disease A case series of 115 patients Movement Disorders 17(4) 682-692

Parsa V amp Jameison DG (2001) Acoustic discrimination of pathological voice Sustained vowels versus continu-ous speech Journal of Speech and Hearing Research 44 327-339

Pahwa R (2006) Understanding Parkinsonrsquos disease An update on current diagnostic and treatment strategies Journal of the American Medical Directors Association 7(Suppl 2) 4-10

Perez K S Ramig L O Smith M E amp Dromey C (1996) The Parkinson larynx Tremor and videostroboscopic findings Journal of Voice 4 354-61

Rahn D A Chou M Zhang Y amp Jiang J J (2007) Phonatory impairment in Parkinsonrsquos disease Evidence from nonlinear dynamic analysis and perturbation analysis Journal of Voice 21 64-71

Ramig L O Countryman S Thompson L L amp Horii Y (1995) Comparison of two forms of intensive speech treatment for Parkinsonrsquos disease Journal of Speech Hearing Research 38 1232-1251

Rascol O Sabatini U Chollet F Fabre N Senard J M Montastruc J L Celsis P Marc-Vergnes J P amp Rascol A (1994) Normal activation of the supplementary motor area in patients with Parkinsonrsquos disease under-going long-term treatment levodopa Journal of Neurol-ogy Neurosurgery and Psychiatry 57 567-571

Sanabria J Ruiz P G Gutierrez R Marquez F Escobar P Gentil M amp Cenjor C (2001) The effect of levo-dopa on vocal function in Parkinsonrsquos disease Clinical neuropharmacology 24(2) 99-102

Schulz G M Peterson T Sapienza C M Greer M amp Friedman W (1999) Voice and speech characteristics of persons with Parkinsonrsquos disease pre- and post- pallidotomy surgery Preliminary findings Journal of Speech Language and Hearing Research 42(5) 1176-1194

Schulz G M amp Grant M K (2000) Effects of speech therapy and pharmacologic and surgical treatments on voice and speech in Parkinsonrsquos disease A review of the literature Journal of Communication Disorders 33 59-88

Sewall G K Jiang J J amp Ford C N (2006) Clinical evaluation of Parkinsonrsquos-related dysphonia Laryn-goscope 116(10) 1740-1744

Sung J E Kim H Kim H S Oh S H Hong J M amp Lee M S (2004) Effects of subthalamic nucleus deep brain stimulation on the phonation and articulation of the patients with Parkinsonrsquos disease Journal of Korean Neurology Association 22(5) 472- 477

Theiler J (1986) Spurious dimension from correlation algo-rithms applied to limited time series data Physical Review A 34 2427-2432

Titze I R (1995) Summary statement Workshop on acoustic voice analysis Proceeding of the National Center for Voice and Speech Denver CO

Titze I R Baken R amp Herzel H (1993) Evidence of chaos in vocal fold vibration I R Titze(Ed)Vocal fold phy-siology Frontiers in basic science (pp 143-188) San Diego CA Singular

Toumlrnqvist A L Schaleacuten L amp Rehncrona S (2005) Effects of different electrical parameter settings on the intel-ligibility of speech in patients with Parkinsonrsquos disease treated with subthalamic deep brain stimulation Movement Disorders 20(4) 416-423

Wang E Verhagen M L Bakay R Arzbaecher J amp Bernard B (2003) The effect of unilateral electrostimulation of the subthalamic nucleus on respiratory phonatory subsystems of speech production in Parkinsonrsquos disease- a preliminary report Clinical Linguistic and Phonetics 17(4-5) 283-289

Xie J Krack P Benabid A L amp Pollak P (2001) Effect of bilateral subthalamic nucleus stimulation on par-kinsonian gait Journal of Neurology 248(12) 1068-1072

Yiu E M(1999) Limitations of perturbation measures in clinical acoustic voice analysis Asia Pacific Journal of Speech Language and Hearing 4 155-166

Zhang Y McGilligan C Zhou L Vig M amp Jiang J J (2004) Nonlinear dynamic analysis of voices before and after surgical excision of vocal polyps Journal of the Acoustical Society of America 115 2270-2277

Zhang Y Jiang J J Biazzo L amp Jorgensen M (2005a) Perturbation and nonlinear dynamic analyses of voices from patients with unilateral laryngeal paralysis Journal of Voice 19 519-528

Zhang Y Jiang J J amp Rahn D A (2005) Studing vocal fold vibrations in Parkinsonrsquos disease with a nonlinear model Chaos 15 33903

Zhang Y Jiang J Wallace S amp Zhou L (2005b) Com-parison of nonlinear dynamic methods and perturbation methods for voice analysis The Journal of the Acoustical Society of America 118 2551-2560

Zhang Y amp Jiang J J (2008) Acoustic analyses of sustained and running voices from patients with laryngeal path-ologies Journal of Voice 22(1) 1-9

최성희 파킨슨씨병 환자의 뇌심부자극술에 대한 말음성 효과

155

본 연구는 부분적으로 구가톨릭 학교와 생체모방감각제어연구소의 연구지원으로 수행되었음

게재 신청일 2012년 1월 19일 최종 수정일 2012년 2월 29일 게재 확정일 2012년 3월 7일

2012 한국언어청각임상학회 httpwwwkasa1986orkr

파킨슨씨병 환자의 뇌심부자극술에 대한 말음성 효과 섭동적 분석과 비선형 역동적 분석을 이용한 연장 발성과 연속 발화 모음의 음향학적 분석

최 성 희sect

구가톨릭 학교 의료과학 학 언어청각치료학과 생체모방감각제어연구소

sect교신저자

최성희대구가톨릭대학교 의료과학대학 언어청각치료학과 교수경산북도 경산시 하양읍 금곡리 5번지e-mail shgracecuackrtel 053-850-3841

배경 및 목적 시상이나 기저핵의 뇌심부자극술은 증상이 중심도로 진행된 파킨슨씨병 환자의

가장 안정되고 장기간 효과를 가지는 신경외과 치료 방법 중 하나로 간주되고 있다 하지만 말과

음성 개선에 한 뇌심부자극술의 효과는 연구마다 일치하지 않거나 역효과가 보고되기도 하

였다 본 연구는 연장 발성과 연속 발화의 모음을 이용하여 전통적인 섭동적 분석과 비선형 역동

적 분석을 통해 뇌심부자극술에 한 말음성의 개선 효과를 조사하는 데 목적을 두고 있다 방법 3～5 H amp Y 단계에 있는 뇌심부자극술-시상핵 자극을 받은 19명의 파킨슨씨병 환자와 뇌심부

자극술-시상핵 자극을 받지 않은 10명의 파킨슨씨병 환자를 각각 치료군과 통제군으로 할당하

였다 파킨슨씨병 환자들은 모두 음성과 발화를 녹음하기 전 밤 사이 12시간 동안 약을 복용하지

않았고 시상핵에 뇌심부자극술을 받은 환자군은 최소한 12시간 동안 자극을 받았고 30분 동

안 휴지기를 가졌다 뇌심부자극술을 받지 않은 통제군과 뇌심부자극술을 받은 환자군으로 연

장발성과 연속 발화에서 모음을 채취하여 percent jitter shimmer SNR과 비선형 역동적 분석

인 D2 값을 얻었고 통계학적으로 분석되었다 결과 뇌심부자극술을 받은 파킨슨씨병 환자군은

통제군에 비해 모음 연장 발성과 연속 발화에서 모두 유의미하게 낮은 D2값을 보였으나(plt

0001) 섭동적 분석에서는 모음 연장 발성과 연속 발화의 모음에서 percent jitter shimmer

SNR가 모두 뇌심부자극술 후 개선을 보이지 않았다 논의 및 결론 비선형 역동적 분석은 뇌심

부자극술의 말음성 개선 치료 효과를 보여주었다 게다가 연속 발화는 짧은 음성 신호 길이와

높은 소음치를 가지기 때문에 연속 발화를 평가할 때 비선형 역동적 분석은 섭동적 분석 방법

을 치할 수 있는 음향학적 측정 방법임을 제시하였다 이러한 결과들은 비선형 역동적 분석이

중심도로 질병이 진행된 파킨슨씨병 환자의 말음성에 한 치료 효과를 평가하는 데 유용하게

사용될 수 있음을 보여주었다 985172언어청각장애연구985173 201217143-155

핵심어 뇌심부자극술 파킨슨씨병 모음 연장 발성 연속 발화 섭동적 분석 비선형 역동적 분석


144

dysarthriarsquo and its typical characteristics include

abnormal prosody variability in speech rate im-

precise movements of the articulators reduced

loudness monotone breathiness and harsh voice

(Hanson Gerratt amp Ward 1984 Gentil amp Pollak

1995 Ramig et al 1995 Sewall Jiang amp Ford

2006) Laryngeal tremor was observed early in the

Parkinsonrsquos disease patients (Perez et al 1996) and

the major laryngeal abnormalities in advanced PD

patients are prominent vocal fold bowing with glottal

incompetence (Blumin Pcolinsky amp Atkins 2004)

hypophonia (Hartelius amp Svensson 1994 Liotti et

al 2003) and abnormal phase closure and phase

asymmetry (Perez et al 1996)

Several studies on PD speech and voice treatment

including pharmacological treatment such as le-

vodopa (Rascol et al 1994 Sanabria et al 2001

Pahwa 2006) neurosurgery such as stereotactic

pallidotomy (Schulz et al1999 Schulz amp Grant

2000) laryngoplasty for vocal folds medialization

(Sewall Jiang amp Ford 2006) have been attempted

to investigate treatment efficacy of parkinsonrsquos re-

lated dysphoinia and dysarthria Although some

results demonstrated clinically significant efficacy

treatment outcomes were limited to small samples

of PD short-term effect or different depended on

different level of dysarthria severity Additionally

levodopa has been used widely to treat symptoms

of PD but the drug side effects including dystonia

and dyskinesia were reported (Parkin et al 2002)

Recently deep brain stimulation (DBS) of the

thalamus or basal ganglia has been considered one

of the most stable and long-term effective neuro-

surgical therapeutic intervention which significantly

improves all areas of limb motor performance such

as rigidity tremor and akinesia (Benabid 2003

Burchiel et al 1999 Iansek Rosenfeld amp Huxham

2002 Krack et al 2003 Kumar amp Mullick 1996

Limousin et al 1998 Xie et al 2001) and preferred

treatment method for patients with advanced PD

due to improvement of the major symptoms of the

disease more effectively than globus pallidus stim-

ulation (Wang et al 2003) The effect of DBS on

speech and voice however has yielded inconsistent

outcomes

Multiple preliminary studies have shown that

DBS of the subthalamic nucleus (STN) improved

maximal phonation time vocal intensity level and

fundamental frequency variability (Gentil et al

2001 Gentil et al 2003 Hoffman-Ruddy et al

2001) In contrast Farrell et al (2005) found that

individuals with PD who had surgery including

thalamotomy pallidotomy or DBS exhibited an im-

proved Hoehn amp Yahr stage of PD score compared

to a non-surgery PD group whereas there were no

significant changes in speech for surgical PD group

Likewise Wang et al (2003) reported subthalamic

nucleus had some positive effects or no changes in

speech and the recent study by Dromey amp Bjarnason

(2011) displayed that articulation (corner vowel

formants diphthong slopes) and phonation (per-

turbation long-term average spectrum) outcomes

showed some speakers improved while others

became worse but only 6 PD with DBS were par-

ticipated in this study Additionally some studies

revealed the DBS effects on speech deteriorated

(Gentil et al 2003 Toumlrnqvist Schaleacuten amp Rehncrona

2005) Sung et al (2004) evaluated maximum

phonation time (MPT) jitter (pitch perturbation)

shimmer (intensity perturbation)tremor indices

and diadochokinetic rate (DDK) to investigate the

effects of DBS with bilateral STN on the phonation

and articulation of 7 PD with levodopa lsquoonrsquo and lsquooffrsquo

treatments They found no significant changes in

the DDK rate under any condition at the articulatory

level and only percent shimmer values decreased

when the patients were levodopa lsquooffrsquo while both

the DBS and levodopa treatment caused significant

prolongation of the MPT suggesting STN DBS

improved phonation but had limited effects on

articulation in individuals with PD in advanced

stage

Acoustic perturbation measures have been com-

monly used as an objective method for evaluation

and diagnose of pathologic voice quality Percent

jitter and shimmer as well as harmonic to noise

ratio (HNR) have traditionally been used to describe

voice quality On the other hand some studies have

cautioned against applying of perturbation acoustic

analysis to severely impared pathologic voice which


145











































































Ⅱ Method

1 Participants












146



Impairment)

PD Duration




4 Male 61 Ⅲ Left 51 0 4 18





9 Female 57 Ⅴ Left 100 2 4 11

10 Male 72 Ⅲ Left 67 1 4 6

11 Male 76 Ⅲ Left 80 1 3 13

12 Male 63 Ⅲ Left 62 1 5 8

13 Male 58 Ⅳ Left 84 1 5 10


15 Female 48 Ⅲ Left 62 0 2 10




19 Male 69 Ⅲ Right 62 1 4 6

MeanSD

NA63877

332(Ⅲ=3

Ⅳ=4 Ⅴ=5)

7142153

07406

3610

93235


























147



Impairment)

PD Duration Since

Diagnosis (years)

1 Female 74 Ⅲ 88 1 3 2

2 Female 74 Ⅳ 100 2 5 5

3 Female 73 Ⅲ 76 1 2 3

4 Female 59 Ⅳ 94 1 3 7

5 Female 57 Ⅲ 64 0 1 6

6 Female 77 Ⅲ 68 0 4 lt1

7 Male 61 Ⅳ 96 1 4 9

8 Male 68 Ⅲ 72 1 4 4

9 Male 49 Ⅲ 62 0 3 2

10 Male 76 Ⅳ 86 2 4 4

MeanSD

NA66897

34(Ⅲ=3

Ⅳ=4 Ⅴ=5)

806139

0907

3311

4226




Surgical PD

(N=19)

Non-surgical

PD (N=10)p-Value

Age(yr) 638(77) 668(97) p gt 005

UPDRSa)

(speech)074(06) 09(07) p gt 005

H amp Yb) 332(06) 34(07) p gt 005

Perceptual

rating36(10) 34(11) p gt 005





































148








3 Data Analysis





















































r log)(loglim

02 rarr=


sum summinus

=

minusminus

=+minusminus

minusminus+=

1 1

0||)||(

))(1(2)(

N

Wn

nN

iniir

WNWNrNWC XXθ



⎩⎨⎧

legt

=0001

)(xx













149

Non

-surgical

group

Surgical

groupp-Value

Sustained

vowel

Percent

jitter

0405

(plusmn0318)

0563

(plusmn0433)01741

Percent

shimmer

6200

(plusmn3169)

6498

(plusmn3550)07393

SNR15336

(plusmn5165)

14407

(plusmn4875)04253

D23585

(plusmn0772)

2648


Running

vowel

Percent

jitter

0851

(plusmn0509)

1108

(plusmn0743)02688

Percent

shimmer

7953

(plusmn4197)

9011

(plusmn4274)03741

SNR12016

(plusmn3758)

13500

(plusmn3385)01291

D24076

(plusmn0990)

3012

(plusmn1340)00002





in phase space















software

Ⅲ Results







group


150



















(p = 2688 p = 3741)























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























145











































































Ⅱ Method

1 Participants












146



Impairment)

PD Duration




4 Male 61 Ⅲ Left 51 0 4 18





9 Female 57 Ⅴ Left 100 2 4 11

10 Male 72 Ⅲ Left 67 1 4 6

11 Male 76 Ⅲ Left 80 1 3 13

12 Male 63 Ⅲ Left 62 1 5 8

13 Male 58 Ⅳ Left 84 1 5 10


15 Female 48 Ⅲ Left 62 0 2 10




19 Male 69 Ⅲ Right 62 1 4 6

MeanSD

NA63877

332(Ⅲ=3

Ⅳ=4 Ⅴ=5)

7142153

07406

3610

93235


























147



Impairment)

PD Duration Since

Diagnosis (years)

1 Female 74 Ⅲ 88 1 3 2

2 Female 74 Ⅳ 100 2 5 5

3 Female 73 Ⅲ 76 1 2 3

4 Female 59 Ⅳ 94 1 3 7

5 Female 57 Ⅲ 64 0 1 6

6 Female 77 Ⅲ 68 0 4 lt1

7 Male 61 Ⅳ 96 1 4 9

8 Male 68 Ⅲ 72 1 4 4

9 Male 49 Ⅲ 62 0 3 2

10 Male 76 Ⅳ 86 2 4 4

MeanSD

NA66897

34(Ⅲ=3

Ⅳ=4 Ⅴ=5)

806139

0907

3311

4226




Surgical PD

(N=19)

Non-surgical

PD (N=10)p-Value

Age(yr) 638(77) 668(97) p gt 005

UPDRSa)

(speech)074(06) 09(07) p gt 005

H amp Yb) 332(06) 34(07) p gt 005

Perceptual

rating36(10) 34(11) p gt 005





































148








3 Data Analysis





















































r log)(loglim

02 rarr=


sum summinus

=

minusminus

=+minusminus

minusminus+=

1 1

0||)||(

))(1(2)(

N

Wn

nN

iniir

WNWNrNWC XXθ



⎩⎨⎧

legt

=0001

)(xx













149

Non

-surgical

group

Surgical

groupp-Value

Sustained

vowel

Percent

jitter

0405

(plusmn0318)

0563

(plusmn0433)01741

Percent

shimmer

6200

(plusmn3169)

6498

(plusmn3550)07393

SNR15336

(plusmn5165)

14407

(plusmn4875)04253

D23585

(plusmn0772)

2648


Running

vowel

Percent

jitter

0851

(plusmn0509)

1108

(plusmn0743)02688

Percent

shimmer

7953

(plusmn4197)

9011

(plusmn4274)03741

SNR12016

(plusmn3758)

13500

(plusmn3385)01291

D24076

(plusmn0990)

3012

(plusmn1340)00002





in phase space















software

Ⅲ Results







group


150



















(p = 2688 p = 3741)























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























146



Impairment)

PD Duration




4 Male 61 Ⅲ Left 51 0 4 18





9 Female 57 Ⅴ Left 100 2 4 11

10 Male 72 Ⅲ Left 67 1 4 6

11 Male 76 Ⅲ Left 80 1 3 13

12 Male 63 Ⅲ Left 62 1 5 8

13 Male 58 Ⅳ Left 84 1 5 10


15 Female 48 Ⅲ Left 62 0 2 10




19 Male 69 Ⅲ Right 62 1 4 6

MeanSD

NA63877

332(Ⅲ=3

Ⅳ=4 Ⅴ=5)

7142153

07406

3610

93235


























147



Impairment)

PD Duration Since

Diagnosis (years)

1 Female 74 Ⅲ 88 1 3 2

2 Female 74 Ⅳ 100 2 5 5

3 Female 73 Ⅲ 76 1 2 3

4 Female 59 Ⅳ 94 1 3 7

5 Female 57 Ⅲ 64 0 1 6

6 Female 77 Ⅲ 68 0 4 lt1

7 Male 61 Ⅳ 96 1 4 9

8 Male 68 Ⅲ 72 1 4 4

9 Male 49 Ⅲ 62 0 3 2

10 Male 76 Ⅳ 86 2 4 4

MeanSD

NA66897

34(Ⅲ=3

Ⅳ=4 Ⅴ=5)

806139

0907

3311

4226




Surgical PD

(N=19)

Non-surgical

PD (N=10)p-Value

Age(yr) 638(77) 668(97) p gt 005

UPDRSa)

(speech)074(06) 09(07) p gt 005

H amp Yb) 332(06) 34(07) p gt 005

Perceptual

rating36(10) 34(11) p gt 005





































148








3 Data Analysis





















































r log)(loglim

02 rarr=


sum summinus

=

minusminus

=+minusminus

minusminus+=

1 1

0||)||(

))(1(2)(

N

Wn

nN

iniir

WNWNrNWC XXθ



⎩⎨⎧

legt

=0001

)(xx













149

Non

-surgical

group

Surgical

groupp-Value

Sustained

vowel

Percent

jitter

0405

(plusmn0318)

0563

(plusmn0433)01741

Percent

shimmer

6200

(plusmn3169)

6498

(plusmn3550)07393

SNR15336

(plusmn5165)

14407

(plusmn4875)04253

D23585

(plusmn0772)

2648


Running

vowel

Percent

jitter

0851

(plusmn0509)

1108

(plusmn0743)02688

Percent

shimmer

7953

(plusmn4197)

9011

(plusmn4274)03741

SNR12016

(plusmn3758)

13500

(plusmn3385)01291

D24076

(plusmn0990)

3012

(plusmn1340)00002





in phase space















software

Ⅲ Results







group


150



















(p = 2688 p = 3741)























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























147



Impairment)

PD Duration Since

Diagnosis (years)

1 Female 74 Ⅲ 88 1 3 2

2 Female 74 Ⅳ 100 2 5 5

3 Female 73 Ⅲ 76 1 2 3

4 Female 59 Ⅳ 94 1 3 7

5 Female 57 Ⅲ 64 0 1 6

6 Female 77 Ⅲ 68 0 4 lt1

7 Male 61 Ⅳ 96 1 4 9

8 Male 68 Ⅲ 72 1 4 4

9 Male 49 Ⅲ 62 0 3 2

10 Male 76 Ⅳ 86 2 4 4

MeanSD

NA66897

34(Ⅲ=3

Ⅳ=4 Ⅴ=5)

806139

0907

3311

4226




Surgical PD

(N=19)

Non-surgical

PD (N=10)p-Value

Age(yr) 638(77) 668(97) p gt 005

UPDRSa)

(speech)074(06) 09(07) p gt 005

H amp Yb) 332(06) 34(07) p gt 005

Perceptual

rating36(10) 34(11) p gt 005





































148








3 Data Analysis





















































r log)(loglim

02 rarr=


sum summinus

=

minusminus

=+minusminus

minusminus+=

1 1

0||)||(

))(1(2)(

N

Wn

nN

iniir

WNWNrNWC XXθ



⎩⎨⎧

legt

=0001

)(xx













149

Non

-surgical

group

Surgical

groupp-Value

Sustained

vowel

Percent

jitter

0405

(plusmn0318)

0563

(plusmn0433)01741

Percent

shimmer

6200

(plusmn3169)

6498

(plusmn3550)07393

SNR15336

(plusmn5165)

14407

(plusmn4875)04253

D23585

(plusmn0772)

2648


Running

vowel

Percent

jitter

0851

(plusmn0509)

1108

(plusmn0743)02688

Percent

shimmer

7953

(plusmn4197)

9011

(plusmn4274)03741

SNR12016

(plusmn3758)

13500

(plusmn3385)01291

D24076

(plusmn0990)

3012

(plusmn1340)00002





in phase space















software

Ⅲ Results







group


150



















(p = 2688 p = 3741)























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























148








3 Data Analysis





















































r log)(loglim

02 rarr=


sum summinus

=

minusminus

=+minusminus

minusminus+=

1 1

0||)||(

))(1(2)(

N

Wn

nN

iniir

WNWNrNWC XXθ



⎩⎨⎧

legt

=0001

)(xx













149

Non

-surgical

group

Surgical

groupp-Value

Sustained

vowel

Percent

jitter

0405

(plusmn0318)

0563

(plusmn0433)01741

Percent

shimmer

6200

(plusmn3169)

6498

(plusmn3550)07393

SNR15336

(plusmn5165)

14407

(plusmn4875)04253

D23585

(plusmn0772)

2648


Running

vowel

Percent

jitter

0851

(plusmn0509)

1108

(plusmn0743)02688

Percent

shimmer

7953

(plusmn4197)

9011

(plusmn4274)03741

SNR12016

(plusmn3758)

13500

(plusmn3385)01291

D24076

(plusmn0990)

3012

(plusmn1340)00002





in phase space















software

Ⅲ Results







group


150



















(p = 2688 p = 3741)























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























149

Non

-surgical

group

Surgical

groupp-Value

Sustained

vowel

Percent

jitter

0405

(plusmn0318)

0563

(plusmn0433)01741

Percent

shimmer

6200

(plusmn3169)

6498

(plusmn3550)07393

SNR15336

(plusmn5165)

14407

(plusmn4875)04253

D23585

(plusmn0772)

2648


Running

vowel

Percent

jitter

0851

(plusmn0509)

1108

(plusmn0743)02688

Percent

shimmer

7953

(plusmn4197)

9011

(plusmn4274)03741

SNR12016

(plusmn3758)

13500

(plusmn3385)01291

D24076

(plusmn0990)

3012

(plusmn1340)00002





in phase space















software

Ⅲ Results







group


150



















(p = 2688 p = 3741)























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























150



















(p = 2688 p = 3741)























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























151
















































2011)












































152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























152






























































treatment effects







Wisconsin-Madison

REFERENCES







153
































154






























155





최 성 희sect


sect교신저자























153
































154






























155





최 성 희sect


sect교신저자























154






























155





최 성 희sect


sect교신저자























155





최 성 희sect


sect교신저자






















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