LSVT Global® Public Webinar Series

Title: Deep Brain Stimulation and LSVT LOUD: Communication Challenges and Treatment Solutions

Presenter: Cynthia Fox, PhD, CCC-SLP

Date Presented: October 23, 2019

Copyright:

The content of this presentation is the property of LSVT Global and is for information purposes only. This content should not be reproduced without the permission of LSVT Global.

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Deep Brain Stimulation and LSVT LOUD: Communication

Challenges and Treatment Solutions

Cynthia Fox, PhD, CCC-SLP

CEO and Co-FounderLSVT LOUD and LSVT BIG Faculty

LSVT Global, Inc.

PLAN FOR

WEBINAR

• Logistics (handouts)

• Presentation of content

• Address your questions

• Survey

Instructor Biography

Cynthia Fox, PhD, CCC-SLPDr. Fox received her doctorate degree in Speech and Hearing Sciences from the University of Arizona, Tucson. Dr. Fox is a research associate at the National Center for Voice and Speech and Co-Founder of LSVT Global. She is an expert on rehabilitation and neuroplasticity and the role of exercise in the improvement of function consequent to neural injury and disease. Dr. Fox is among the world’s experts in speech treatment for people with Parkinson disease. She has multiple publications in this area of focus, as well as numerous national and international research and clinical presentations. She is an expert on rehabilitation and neuroplasticity and the role of exercise in the improvement of function consequent to neural injury and disease.

Disclosures

• Non-financial relationships include a preferencefor the LSVT LOUD as a treatment technique.

• Financial Relationships include Dr. Fox is anemployee of LSVT Global and receives lecturehonorarium. Dr. Fox has ownership interest inthe company.

Information to Self-Report Continuing Education Activity

• This LSVT Global webinar is NOT ASHA or state registered for CEUs, but it may be used for self-reported CEU credit as a non-registered CEU activity.

• If you are a speech therapy professional and would like to self-report your activity, e-mail webinars@lsvtglobal.com to request a certificate after completion of the webinar which will include your name, date and duration of the webinar.

• Licensing requirements for CEUs differ by state. Check with your state licensing board to determine if your state accepts non-ASHA registered CEU activities.

• Attendance for the full hour is required to earn a certificate.

Learning Objectives

Upon conclusion of this webinar, participants will be able to:

1. Describe voice and speech changes following DBS surgery

2. Explain how LSVT LOUD may improvecommunication post-DBS

3. Outline adaptations that can facilitate and optimize positive outcomes

4. Highlight future adaptations that may improve speechoutcomes

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Poll: Who’s in our audience today?

• Person with Parkinson’s disease

• Family or friend of person with Parkinson’sdisease

• Speech-language pathologist – professional

• Speech-language pathologist – student

• Other

What is Deep Brain Stimulation?

Deep brain stimulation (DBS) uses a surgically implanted medical device to deliver electrical stimulation to a targeted area in the brain. It electrically stimulates specific structures that control unwanted symptoms.

Deep Brain Stimulation in PD

• Placement of electrodes in the Subthalamic Nucleus (STN) or Globus Pallidus Interna (GPi)

Images from Parkinson.org

Deep Brain Stimulation in PD

• Connected to a neurostimulator (~pacemaker) under the clavicle area

• Can be done unilateral or bilaterally

• Consists of multiple surgeries to place electrodes and stimulators

Candidate selection for

DBS

• Diagnosis of idiopathic Parkinson’s disease

• Robust and sustained response to levodopa medications and substantial motor disability

• Absence of dementia or unstable neuropsychiatric symptoms

• Absence of considerable surgical and medical risk factors

• Individual symptoms, needs and goals should be considered in target site selection

Ramirez-Zamora & Ostrem, 2018

How does DBS affect symptoms of PD?

• Can reduce &/or control rigidity, bradykinesia/akinesia, tremor & dyskinesia

• Patient can only return to their best “on time”

• Can reduce amount of meds needed (~30%)

• STN can lead to depression, apathy, impulsivity, worsened verbal fluency, & executive dysfunction

• Not as effective on gait & balance or postural instability

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Potential DBS Complications

Intracranial or intracerebral hemorrhage in 2% of patients

Ischemic stroke in 0-1%

Implantation site infection 3-8%

Seizures in 0-3% of patients

Suicidal ideation may increase after DBS

Declines in cognition in longitudinal follow up have been documented

Possible decline in speech, gait & balance

Duker & Espay, 2013

Dysarthria following DBS of the STN vs. GPI

• Speech function seems to be less compromised under GPi-DBS than under STN-DBS, but further study needed. Skodda, 2012

Pre-existing speech factors to consider pre-DBS

• Lower preoperative speech intelligibility

• Longer disease duration

Tripoliti et al., 2014

• Higher overall motor and speech scores on UPDRS III (higher is worse)

• Preexisting pattern of • Articulatory slurring and hastening• Acceleration of speech

Skodda et al., 2014

Describe voice and speech changes following DBS surgery

Speech characteristics post-DBS

• Neurosurgical interventions do not consistently or effectively improve speech in PD Freed et al., 1992; Goberman, 2005; Pinto et al., 2004; Rousseaux et al., 2004

• While some individual components of speech may improve, e.g., loudness of sustained phonation, oral force control of tongue; Overall speech intelligibility is not improved Kostermann et al., 2008; Pinto et al., 2003

• Speech problems (dysarthria) reported after STN-DBS ranges: 5% - 61% Krack et al., 2003; Guehl et al., 2006

Speech characteristics post-DBS from the patient perspective

• Significant differences in severity of perceived speech disturbance between DBS and non-DBS group

• More severe symptoms reported

• More symptom interference with social interaction and daily experiences relating to functional, physical and emotional issues of a voice disorder

• Low volume was the “most common” speech symptom

• DBS had the greatest adverse impact on “slurred speech.”

Wertheimer et al., 2014

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Medial versus lateral speech profile post-DBSMahlknecht et al., 2017

Medial

• Strained-tight and continuous phonation

• Inaccurate articulation

• Perception of breathing insufficiency

• More dystonic and less responsive to behavioral therapy

Lateral

• Monotone-flat intonation

• Fast rate of speech

• Reduced movement of lips and tongue

• More hypokinetic and respond well to LSVT LOUD, but may have added fatigue and some apathy

Longitudinal Impact on Speech

• 32 patients bilateral STN-DBS at 1 year; 15 at3 years and 12 in medical (no surgery) group

• Speech assessed at baseline, post-DBS 1month, 6 months, 1 and 3 years

• Speech intelligibility deteriorated 1 year afterDBS in 78% of patients in contrast to marked50.7% improvement in parkinsonian motorsymptoms

Tripoliti et al., 2011

Tripoliti et al., 2011

Factors affecting speech outcomes post-DBSSurgical

• Contact placement

• Stimulator settings (frequency, voltage, pulse width)

• Unilateral vs. bilateral stimulation

• Spread of stimulation to other structures

Medical

• Parkinson disease severity

• Severity of speech disorder pre-DBS

• Medication

Methodological

• Selection and number of subjects in studies

• Speech measurement tools vs. UPDRS-III

• Time post surgery studies

Consensus on medical management in PD

Magnitude and consistency of speech improvement with drugs and surgery not the same as limb improvement

Goberman, 2005; Schulz & Grant, 2000; Trail et al., 2005

Explain how LSVT LOUD may improve communication post-DBS

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Speech rehab focus post-DBS

• Maintain and improve physical capacityLoudness, voice quality,

intelligibility, rate

• Maintain vital functions: swallowing safely

• Functional communication is key

• Use of external cueing, devices, augmentative devices

• Address cognitive and/or language deficits

Treat Early and Often!

Our work – LSVT Protocols:Based on 30+ years of NIH funded research 

and clinical experience

LSVT LOUD is a speech therapy 

Delivered by LSVT LOUD Certified Speech‐

Language Pathologists

LSVT BIG is a physical/occupational 

therapy

Delivered by LSVT BIG Certified Physical Therapists or 

Occupational Therapists

30+ year LSVT LOUD journey from invention to scale-up

1987-89: Initial invention; Pilot data Lee Silverman Center

1989-91: Treatment development OE-NIDRR

1991-94: Treatment follow-up OE-NIDRR

1990-95: Treatment Efficacy NIH R01 RCT

1995-00: Underlying Mechanism NIH R01 RCT

2002-07: Distributed effects NIH R01

2007-12: Target/mode NIH R01 RCT

2001-02: LSVT Companion Coleman Institute

2002-04: LSVT Companion NIH & MJ FOX Foundation NIH R21

2002-04: LSVT Virtual Therapist Coleman Institute

2004-06: LSVT Virtual Therapist NIH R21

2004: LSVT Down Syndrome Coleman Institute

2006: Technology Enhanced Clinician Training NIH SBIR

2009: Telehealth Delivery of Software Enhanced LSVT NIH SBIR

2010: Independent Delivery of Software Enhanced LSVT NIH SBIR

1993-present: Global LSVT LOUD Training & Certification Courses

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Evidence for LSVT LOUD3 Randomized Controlled Trials

Change in dB SPL During Reading (50 cm)0cm)

1st RCT; n=45LSVT: Voice/respiratory targetRESP: Respiratory target

Pre, Post, 6 mos, 12 mos, 24 mos

Ramig et al., 1995; 1996, 2001a

2nd RCT; n=30LSVT: Voice/respiratory targetUnTx: No treatment

Pre, Post, 6 mos

Ramig et al., 2001b

3rd RCT; n=64LSVT: Voice/respiratory targetARTIC: Articulatory target UnTx: No Treatment

Pre, Post 6 mos

Ramig et al., 2018

Study Designs• Matched dosage• Matched intensity• Matched homework• Matched therapists’

enthusiasm• Blinded data

analysis• Uncued tasks• Data collected by

someone other than therapist

Spielman, et al., 2003Dumer et al., 2014

Facial expression

El‐Sharkawi, et al, 2002: Miles et al., 2017

Swallowing

Smith, et al., 1995

Adduction

Ramig & Dromey, 1996

Aerodynamics

Baker, 1998; Luschei, 1999 

Electromyography (EMG)

Liotti, et al.,  2003Narayana, et al.,  2010Baumann et al., 2018

Neural Imaging Dromey, 1995; Cannito et al., 2012 

Articulation/Intelligibility

Sapir, et al., 2007; 2010

Articulatory acoustics

Smith, A., 2001

Speech Motor Stability

Taskoff, 2001

Perceptual

Beyond Efficacy – numerous studies (over 30) examining distributed effects, neural correlates, mechanism of change

Ramig et al., 1995; 1996; 2001

Intonation (STSD)

Baumgartner et al., 2001

Voice Quality

LSVT LOUD Treatment SessionDaily Exercises

1. Maximum Duration ofSustained Vowel Phonation (Long Ahs) – 15+ reps

2. Maximum Fundamental Frequency Range (High/Low Ahs) – 15 reps each

3. Maximum Functional SpeechLoudness (Functional Phrases) – 5 reps of 10 phrases

Hierarchy Exercises

Structured reading and spontaneous speaking – 25 min

Build complexity across 4 weeks of treatment 

Week 1 – words, phrases

Week 2 – sentences

Week 3 – reading

Week 4 ‐ conversation

Homework

Includes all daily exercises and hierarchy exercises.  Assigned all 30 days

Carryover Exercises

Use loud voice in real life outside of the treatment room.  Assigned all 30 days

Shorter, simple

Longer, complex

Core amplitude rescaling exercises

Translation of amplitude to functional, salient, 

individualized goals

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Speech treatment post-DBS in Parkinson’s disease – limited research

• LSVT LOUD case series:Spielman et al., 2011

• LSVT LOUD post STN-DBSsmall groups:Tripoliti et al, 2011

VIDEO – LSVT LOUD POST-DBS

N=4/group

N=4/group

LSVT LOUD pre/post STN-DBS Spielman et al., 2011

Feedback from treating clinicians:

• Subjects had great difficulty producing targetphonations and loud speech during exercises

• Persistent hoarse voice quality, severe slurring,impaired tongue control

• Difficulty with carryover of improved voice intoconversational speech

One possible explanation for this is the high stimulator settings for these three subjects, which has been shown to negatively affect speech intelligibility

Tornqvist et al., 2005; Tripoliti et al, 2008

• 20 participants: medical or surgical groups

• Measured pre, post, and FU

• LSVT LOUD treatment administered

• Examined acoustics, speech intelligibility andperceptual measures LSVT LOUD improved vocal loudness for medical group, but not for STN‐DBS group. 

Participants post STN‐DBS were variable in response to LSVT LOUD with minimal sustained improvements. 

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LSVT LOUD and CLEAR

• 3 patients with IPD, post bilateral DBS-STN, receiving LSVT followed by a two week (8 sessions) regimen of additional training (“loud and clear”) to improve articulation.

• Loud + Clear. A regimen designed to augment the LSVT effects by proving additional training in high effort oral speech articulation.

Halpern et al., 2010 poster presentation

Vocal Sound Pressure level (dB SPL) for conversation and reading the Rainbow Passage

LSVT_LC dB SPL Pre, Post, 6wk

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CONV

RAINBOW

Interview: Patients’ Responses Regarding Additional Treatment outcome

How would your speech be w/o the additional

Tx

Repeat less?

Easier to use voice strategies

outside Tx?Speech clearer?

Outcome better or

same?Patient

Loud but not as clear

yesyesyesbetterDBS-6

IDKI can’t recallIDKyesbetterDBS-7

Loud but less clear,

mumbled

yesOnce loudness was indoctrinated this allowed me to

improve

articulation of consonants

yesbetterDBS-9

Self Ratings of Communication Effectiveness (CETI-M)

LSVT_LC CETI-M Pre, Post, 6wk

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Outline adaptations that can facilitate and optimize positive outcomes

LSVT LOUD Adaptations

Adaptations ARE:• Increasing repetitions for shorter durations

• Allowing greater rest breaks

• Persisting at phrase/sentence levels of the hierarchy

• Utilizing family and support system for carryover

• Altering materials for visual/language impairments

• Adding additional sessions and more frequent follow-ups

Adaptations are NOT:• Altering core protocol

• Delivering fewer or shorter sessions

• Changing treatment tasks

• Eliminating core elements (target, mode, calibration)

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Adaptation Examples During Treatment• May need to spend more time shaping and modeling good voice

quality during all daily exercises and speech hierarchy exercises

• You may model shorter durations to facilitate better voice quality

• Longer rest periods between repetitions and speech hierarchy exercises

• For medial speech profile, it may be helpful to have shorter duration reps of the “ah” and break up the sequence: 5 short and loud ahs followed by 3 highs/3 lows then speaking then back to 5 short and loud and so on

• Focus on shorter functional phrases for more severe speech impairments

• May take longer for calibration to “kick in” due to cognitive changes post-DBS

• May be increased frustration due to fatigue

Adaptations: General• Repetition, repetition, repetition!!!

• Keep focus simple, even when other communication deficits are present

• Acknowledge a patient’s fatigue within treatment sessions (e.g.,

validate; longer rest periods)

• Frequent and continuous follow-up

• Delayed auditory feedback: http://www.speechvive.com/

• Altered auditory feedback: https://speecheasy.com/speecheasy-pd/?gclid=EAIaIQobChMIpL2zqoSL5QIVjSCtBh1qyAO8EAAYASAAEgLfAfD_BwE

• Augmentative device supplementation

• Pacing – alphabet board, tactile cue, clicking pen

• Additional cues – e.g. “loud and fast”; “loud and clear”

• Don’t discount successful treatment options just because the speech is severe and/or complex

• Do stimulabililty testing and a week of trial treatment

• You can be amazed at some of the outcomes

• FUNCTIONAL oral communication of any kind can dramatically improve quality of life (even ifsupplementation is required)

Give everyone a chance! Multi-disciplinary team is key!

MEDICAL TEAM

• Neurologist

• Neurosurgeon

• General practice physician

• Nurses

• CNP/PA in Neurology

• Physiatrist

• Pharmacist

• Speech therapists

• Physical therapists

• Occupational therapists

• Clinical neuropsychologist

• Social workers

• Nutritionist

Behavioral intervention is the most EFFECTIVE therapy for improving communication!

ALLIED TEAM

Recommendations

Optimize Stimulator Settings for Speech • Have a team approach with the neurologist/neurosurgeon and speech

therapist to adjust stimulation and find the best contact and voltage settings

Behavioral Speech Treatment• LSVT LOUD four weeks – gold standard

• Additional week or more (as needed)

• Additional follow-up 1-3 Months

Severe Speech Impairments from Stimulation• Trials of behavioral speech treatment

• May need addition of augmentative communication devices

Highlight future adaptations that may improve speech outcomes

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• Adaptive DBS - DBS system that uses feedback from the brain itself to fine-tune its signaling versusconstant electrical stimulation to the brain regions Little, Tripoliti, et al., 2016

• Shortening pulse width Dayal et al., 2019

• Low frequency stimulation Fabbri et al., 2019

• Combination of lower frequency, lower pulse width,and higher voltage settings Abeyeskera et al., 2019

Future potential advances to improve speech outcomes post-DBS

• Pre-treat with LSVT LOUD before DBS surgeryTripoliti “With LSVT pre we have had greatimprovement in outcomes.”

• Voice banking pre-DBS• Voice banking to preserve voice for future

augmentative device (if needed)• Voice banking as a speech hierarchy exercise if

receiving LSVT LOUD pre-DBS• https://vocalid.ai/

Future potential advances to improve speech outcomes post-DBS

Summary

• Voice and speech changes can occur following DBS surgery

• Behavioral speech treatment, such as LSVT LOUD, may improve communication post-DBS

• Adaptations can be made that facilitate and optimize positive outcomes

• Future research on adaptations to surgery, stimulationparameters or timing of behavioral treatment have thepossibility of improving speech outcomes

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Application of LSVT LOUD® to Individuals Post Deep Brain Stimulation: Webinar References

Abeyesekera A, Adams S, Mancinelli C, Knowles T, Gilmore G, Delrobaei M, Jog M. (2019). Effects of Deep Brain Stimulation of the Subthalamic Nucleus Settings on Voice Quality, Intensity, and Prosody in Parkinson's Disease: Preliminary Evidence for Speech Optimization. Canadian Journal of Neurological Sciences, 46(3), 287-294.

Dayal V, Grover T, Tripoliti E, Milabo C, Salazar M, Candelario-McKeown J, Athauda D, Zrinzo L, Akram H, Hariz M, Limousin P, Foltynie T. (2019). Short Versus Conventional Pulse-Width Deep Brain Stimulation in Parkinson's Disease: A Randomized Crossover Comparison. Movement Disorders. Sep 30. doi: 10.1002/mds.27863. [Epub ahead of print]

Duker AP, Espay AJ. (2013). Surgical treatment of Parkinson disease: past, present, and future. Neurology Clinics Journal, 31(3), 799-808.

Fabbri M, Zibetti M, Ferrero G, Accornero A, Guimaraes I, Rizzone MG, Romagnolo A, Ferreira JJ, Lopiano L. (2019). Is lowering stimulation frequency a feasible option for subthalamic deep brain stimulation in Parkinson's disease patients with dysarthria? Parkinsonism Related Disorders, 64, 242-248.

Freed CR, Breeze RE, Rosenberg NL, Schneck SA, Kriek E, Qi JX, Lone T, Zhang YB, Snyder JA, Wells TH, et al. (1992). Survival of implanted fetal dopamine cells and neurologic improvement 12 to 46 months after transplantation for Parkinson's disease. New England Journal of Medicine, 327(22), 1549-55.

Goberman AM. (2005). Correlation between acoustic speech characteristics and non-speech motor performance in Parkinson Disease. Medical Science Monitor, 11(3), CR109-16.

Guehl D, Cuny E, Benazzouz A, Rougier A, Tison F, Machado S, Grabot D, Gross C, Bioulac B, Burbaud P. (2006). Side-effects of subthalamic stimulation in Parkinson's disease: clinical evolution and predictive factors. European Journal of Neurology, 13(9), 963-71.

Halpern A, Spielman J, Ramig L, Gilley PM. (2010). Speech treatment for individuals with IPD post deep brain stimulation: LSVT-DBS, Movements Disorders, 25(S2), S452-S453.

Hariz M, Rehncrona S, Quinn NP, Speelman JD, Wensing C. (2008). Multicenter study on deep brain stimulation in Parkinson’s disease: an independent assessment of reported adverse events at 4 years. Movement Disorders, 15, 416-421.

Klostermann F, Ehlen F, Vesper J, Nubel K, Gross M, Marzinzik F, Curio G, Sappok T. (2008). Effects of subthalamic deep brain stimulation on dysarthrophonia in Parkinson's disease. Journal of Neurology Neurosurgery & Psychiatry, 79(5), 522-9.

Krack P, Batir A, Van Blercom N, Chabardes S, Fraix V, Ardouin C, Koudsie A, Limousin PD, Benazzouz A, LeBas JF, Benabid AL, Pollak P. (2003). Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson's disease. New England Journal of Medicine, 349(20), 1925-34.

Little S, Tripoliti E, Beudel M, et al. (2016). Adaptive deep brain stimulation for Parkinson’s disease demonstrates reduced speech side effects compared to conventional stimulation in the acute setting. Journal of Neurology, Neurosurgery and Psychiatry, 87, 1388-1389.

Mahlknecht P, Akram H, Georgiev D, Tripoliti E, Candelario J, Zacharia A, Zrinzo L, Hyam J, Hariz M, Foltynie T, Rothwell JC, Limousin P. (2017). Pyramidal tract activation due to subthalamic deep brain stimulation in Parkinson's disease. Movement Disorders, 32(8), 1174-1182.

Pinto S, Gentil M, Fraix V, Benabid AL, Pollak P. (2003). Bilateral subthalamic stimulation effects on oral force control in Parkinson's disease. Journal of Neurology, 250(2), 179-87.

Pinto S, Ozsancak C, Tripoliti E, Thobois S, Limousin-Dowsey P, Auzou P. (2004). Treatments for dysarthria in Parkinson's disease. Lancet Neurology, 3(9), 547-56.

(2018). Globus Pallidus Interna or Subthalamic Nucleus Deep Brain Stimulation for Parkinson Disease: A Review. JAMA Neurology, 75(3), 367-372.

Rousseaux M, Krystkowiak P, Kozlowski O, Özsancak C, Blond S, Destée A. (2004). Effects of subthalamic nucleus stimulation on parkinsonian dysarthria and speech intelligibility. Journal of Neurology, 251 (3), 327–334.

Schulz GM, Grant MK. (2000). Effects of speech therapy and pharmacologic and surgical treatments on voice and speech in Parkinson's disease: a review of the literature. Journal of Communication Disorders, 33(1), 59-88.

Spielman J, Mahler L, Halpern A, Gilley P, Klepitskaya O, Ramig L. (2011). Intensive voice treatment (LSVT®LOUD) for Parkinson's disease following deep brain stimulation of the subthalamic nucleus. Journal of Communication Disorders, 44(6), 688-700.

Skodda, S. (2012). Effect of deep brain stimulation on speech performance in Parkinson's disease. Parkinson’s Disease, 850596. doi: 10.1155/2012/850596. Epub 2012 Nov 21.

Skodda S, Grönheit W, Schlegel U, Südmeyer M, Schnitzler A, Wojtecki L. (2014). Effect of subthalamic stimulation on voice and speech in Parkinson’s disease: for the better or worse? Frontiers in Neurology, 4, 1-10.

Trail M, Fox C, Ramig LO, Sapir S, Howard J, Lai EC. (2005). Speech treatment for Parkinson's disease. NeuroRehabilitation, 20(3), 205-21.

Tripoliti E, Zrinzo L, Martinez-Torres I, Frost E, Pinto S, Foltynie T, Holl E, Petersen E, Roughton M, Hariz MI, Limousin P. (2005). Effects of subthalamic stimulation on speech of consecutive patients with Parkinson disease. Neurology, 76(1), 80-6.

Tripoliti E, Strong L, Hickey F, Foltyne T, Arinzo L, Candelario J, Hariz M, Limousin P. (2011). Treatment of dysarthria following subthalamic nucleus deep brain stimulation for Parkinson’s disease. Movement Disorders, 26(13), 2432-2436.

Tripoliti E, Limousin P, Foltynie T, Candelario J, Aviles-Olmos I, Hariz MI, Zrinzo L. (2014). Predictive factors of speech intelligibility following subthalamic nucleus stimulation in consecutive patients with Parkinson's disease. Movement Disorders, 29(4), 532-8.

Wertheimer J, Gottuso AY, Nuno M, Walton C, Duboille A, Tuchman M, Ramig L. (2014). The impact of STN deep brain stimulation on speech in individuals with Parkinson's disease: the patient's perspective. Parkinsonism Related Disorders, 20(10), 1065-70.