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Effects of the Lee Silverman Voice Treatment (LSVT® LOUD) on Hypomimia in Parkinson's Disease

  • Aleksey I. Dumer (a1) (a2), Harriet Oster (a3), David McCabe (a1) (a2), Laura A. Rabin (a2) (a4), Jennifer L. Spielman (a5), Lorraine O. Ramig (a5) (a6) and Joan C. Borod (a1) (a2) (a7)...


Given associations between facial movement and voice, the potential of the Lee Silverman Voice Treatment (LSVT) to alleviate decreased facial expressivity, termed hypomimia, in Parkinson's disease (PD) was examined. Fifty-six participants—16 PD participants who underwent LSVT, 12 PD participants who underwent articulation treatment (ARTIC), 17 untreated PD participants, and 11 controls without PD—produced monologues about happy emotional experiences at pre- and post-treatment timepoints (“T1” and “T2,” respectively), 1 month apart. The groups of LSVT, ARTIC, and untreated PD participants were matched on demographic and health status variables. The frequency and variability of facial expressions (Frequency and Variability) observable on 1-min monologue videorecordings were measured using the Facial Action Coding System (FACS). At T1, the Frequency and Variability of participants with PD were significantly lower than those of controls. Frequency and Variability increases of LSVT participants from T1 to T2 were significantly greater than those of ARTIC or untreated participants. Whereas the Frequency and Variability of ARTIC participants at T2 were significantly lower than those of controls, LSVT participants did not significantly differ from controls on these variables at T2. The implications of these findings, which suggest that LSVT reduces parkinsonian hypomimia, for PD-related psychosocial problems are considered. (JINS, 2014, 20, 1–11)


Corresponding author

Correspondence and reprint requests to: Aleksey I. Dumer, Center for Enhanced Performance, United States Military Academy, West Point, New York 10996. E-mail:


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Aarsland, D., Påhlhagen, S., Ballard, C.G., Ehrt, U., Svenningsson, P. (2012). Depression in Parkinson disease – Epidemiology, mechanisms and management. Nature Reviews Neurology, 8, 3547.
Beck, A.T., Steer, R.A., Brown, G.K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychology Corporation.
Benjamini, Y., Hochberg, Y. (1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal Statistical Society, 57(Series B), 289300.
Best, C., Taylor, N. (1966). The physiological basis of medical practice; A text in applied physiology (8th ed.). Baltimore, MD: Williams & Wilkins.
Bologna, M., Fabbrini, G., Marsili, L., Defazio, G., Thompson, P.D., Berardelli, A. (2012). Facial bradykinesia. Journal of Neurology, Neurosurgery, and Psychiatry, 0, 15. doi:10.1136/jnnp-2012-303993
Borod, J.C., Tabert, M.H., Santschi, C., Strauss, E. (2000). Neuropsychological assessment of emotional processing in brain-damaged patients. In J. C. Borod (Ed.), The neuropsychology of emotion (pp. 80105). New York, NY: Oxford University Press.
Borod, J.C., Welkowitz, J., Obler, L.K. (1992). The New York Emotion Battery. Unpublished materials. New York, NY: Department of Neurology, Mount Sinai Medical Center.
Bowers, D., Miller, K., Bosch, W., Gokcay, D., Pedraza, O., Springer, U., Okun, M. (2006). Faces of emotion in Parkinson's disease: Micro-expressivity and bradykinesia during voluntary facial expressions. Journal of the International Neuropsychological Society, 12, 765773.
Brozgold, A.Z., Borod, J.C., Martin, C.C., Pick, L.H., Alpert, M., Welkowitz, J. (1998). Social functioning and facial emotional expression in neurological and psychiatric disorders. Applied Neuropsychology, 5, 1523.
Busso, C., Narayanan, S.S. (2007). Interrelation between speech and facial gestures in emotional utterances: A single subject study. IEEE Transactions on Audio, Speech, and Language Processing, 15, 23312347.
Crum, R.M., Anthony, J.C., Bassett, S.S., Folstein, M.F. (1993). Population-based norms for the Mini–Mental State Examination by age and education level. The Journal of the American Medical Association, 269, 23862391.
Desmurget, M., Grafton, S.T., Vindras, P., Gréa, H., Turner, R.S. (2004). The basal ganglia network mediates the planning of movement amplitude. European Journal of Neuroscience, 19, 28712880.
Dromey, C., Ramig, L.O. (1998). Intentional changes in sound pressure level and rate: Their impact on measures of respiration, phonation, and articulation. Journal of Speech, Language, and Hearing Research, 41, 10031018.
Ekman, P., Friesen, W.V. (1978). Facial action coding system: A technique for the measurement of facial movement. Palo Alto, CA: Consulting Psychologists Press.
Ekman, P., Friesen, W.V., Hager, J.C. (2002). Facial Action Coding System: Investigator's guide. Salt Lake City, UT: Research Nexus.
El Sharkawi, A., Ramig, L., Logemann, J., Pauloski, B., Rademaker, A., Smith, C., Werner, C. (2002). Swallowing and voice effects of Lee Silverman Voice Treatment: A pilot study. Journal of Neurology, Neurosurgery, and Psychiatry, 72, 3136.
Elefant, C., Lotan, M., Baker, F.A., Skeie, G.O. (2012). Effects of music therapy on facial expression of individuals with Parkinson's disease: A pilot study. Musicae Scientiae, 16, 392400.
Erceg-Hurn, D.M., Mirosevich, V.M. (2008). Modern robust statistical methods: An easy way to maximize the accuracy and power of your research. American Psychologist, 63, 591601.
Folstein, M.F., Folstein, S.E., McHugh, P.R. (1975). “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189198.
Fridlund, A.J., Ekman, P., Oster, H. (1987). Facial expressions of emotion. In A. Siegman & S. Feldstein (Eds.), Nonverbal behavior and communication (pp. 143224). Hillsdale, NJ: Erlbaum.
Frisina, P.G., Borod, J., Foldi, N.S., Tenenbaum, H.R. (2008). Depression in Parkinson's disease: Health risks, etiology, and treatment options. Neuropsychiatric Disease and Treatment, 4, 8191.
Glass, G.V., McGaw, B., Smith, M.L. (1981). Meta-analysis in social research. Beverly Hills, CA: SAGE Publications.
Hall, P. (1992). On the removal of skewness by transformation. Journal of the Royal Statistical Society, 54(Series B), 221228.
Hemmesch, A.R., Tickle-Degnen, L., Zebrowitz, L.A. (2009). The influence of facial masking and sex on older adults’ impressions of individuals with Parkinson's disease. Psychology and Aging, 24, 542549.
Ho, A.K., Bradshaw, J.L., Iansek, R., Alfredson, R. (1999). Speech volume regulation in Parkinson's disease: Effects of implicit cues and explicit instructions. Neuropsychologia, 37, 14531460.
Hoehn, M.M., Yahr, M.D. (1967). Parkinsonism: Onset, progression and mortality. Neurology, 17, 427442.
Hopf, H.C., Muller-Forell, W., Hopf, N.J. (1992). Localization of emotional and volitional facial paresis. Neurology, 42, 19181923.
Iwase, M., Ouchi, Y., Okada, H., Yokoyama, C., Nobezawa, S., Yoshikawa, E., Watanabe, Y. (2002). Neural substrates of human facial expression of pleasant emotion induced by comic films: A PET Study. Neuroimage, 17, 758768.
Jürgens, U. (2002). Neural pathways underlying vocal control. Neuroscience and Biobehavioral Reviews, 26, 235258.
Katsikitis, M., Pilowsky, I. (1988). A study of facial expression in Parkinson's disease using a novel microcomputer-based method. Journal of Neurology, Neurosurgery, and Psychiatry, 51, 362366.
Katsikitis, M., Pilowsky, I. (1991). A controlled quantitative study of facial expression in Parkinson's disease and depression. The Journal of Nervous and Mental Disease, 179, 683688.
Katsikitis, M., Pilowsky, I. (1996). A controlled study of facial mobility treatment in Parkinson's disease. Journal of Psychosomatic Research, 40, 387396.
Kazandjian, S., Borod, J.C., Brickman, A.M. (2007). Facial expression during emotional monologues in unilateral stroke: An analysis of monologue segments. Applied Neuropsychology, 14, 235246.
Kenward, M.G., Roger, J.H. (2009). An improved approximation to the precision of fixed effects from restricted maximum likelihood. Computational Statistics & Data Analysis, 53, 25832595.
Keselman, H.J., Algina, J., Lix, L.M., Wilcox, R.R., Deering, K. (2008). A generally robust approach for testing hypotheses and setting confidence intervals for effect sizes. Psychological Methods, 13, 110129.
Keselman, H.J., Othman, A.R., Wilcox, R.R., Fradette, K. (2004). The new and improved two-sample t test. Psychological Science, 15, 4751.
Keselman, H.J., Wilcox, R.R., Othman, A.R., Fradette, K. (2002). Trimming, transforming statistics, and bootstrapping: Circumventing the biasing effects of heteroscedasticity and nonnormality. Journal of Modern Applied Statistical Methods, 1, 288309.
Liotti, M., Ramig, L.O., Vogel, D., New, P., Cook, C.I., Ingham, R.J., Fox, P.T. (2003). Hypophonia in Parkinson's disease: Neural correlates of voice treatment revealed by PET. Neurology, 60, 432440.
McClean, M.D., Tasko, S.M. (2002). Association of orofacial with laryngeal and respiratory motor output during speech. Experimental Brain Research, 146, 481489.
Miller, N., Andrew, S., Noble, E., Walshe, M. (2011). Changing perceptions of self as a communicator in Parkinson's disease: A longitudinal follow-up study. Disability and Rehabilitation, 33, 204210.
Miller, N., Noble, E., Jones, D., Burn, D. (2006). Life with communication changes in Parkinson's disease. Age and Ageing, 35, 235239.
Monrad-Krohn, G.H. (1924). On the dissociation of voluntary and emotional innervation in facial paresis of central origin. Brain, 47, 2235.
Monrad-Krohn, G.H. (1957). The third element of speech: Prosody in the neuro-psychiatric clinic. The Journal of Mental Science, 103, 326331.
Montreys, C.R., Borod, J.C. (1998). A preliminary evaluation of emotional experience and expression following unilateral brain damage. International Journal of Neuroscience, 96, 269283.
Narayana, S., Fox, P.T., Zhang, W., Franklin, C., Robin, D.A., Vogel, D., Ramig, L.O. (2010). Neural correlates of efficacy of voice therapy in Parkinson's disease identified by performance-correlation analysis. Human Brian Mapping, 31, 222236.
Nijhof, G. (1995). Parkinson's disease as a problem of shame in public appearance. Sociology of Health & Illness, 17, 193205. doi:10.1111/1467-9566.ep10933386
Pentland, B., Gray, J.M., Riddle, W.J., Pitcairn, T.K. (1988). The effects of reduced non-verbal communication in Parkinson's disease. British Journal of Disorders of Communication, 23, 3134.
Pentland, B., Pitcairn, T.K., Gray, J.M., Riddle, W.J. (1987). The effects of reduced expression in Parkinson's disease on impression formation by health professionals. Clinical Rehabilitation, 1, 307312.
Pernet, C.R., Wilcox, R., Rousselet, G.A. (2013). Robust correlation analyses: False positive and power validation using a new open source Matlab toolbox. Frontiers in Psychology, 3, 118. doi:10.3389/fpsyg.2012.00606
Ramig, L.O., Countryman, S., Thompson, L.L., Horii, Y. (1995). Comparison of two forms of intensive speech treatment for Parkinson disease. Journal of Speech, Language, and Hearing Research, 38, 12321251.
Ramig, L., Fox, C., Sapir, S. (2008). Speech treatment for Parkinson's disease. Expert Reviews in Neurotherapeutics, 8, 297309.
Ramig, L., Sapir, S., Countryman, S., Pawlas, A., O'Brien, C., Hoehn, M., Thompson, L. (2001). Intensive voice treatment (LSVT) for patients with Parkinson's disease: A 2 year follow up. Journal of Neurology, Neurosurgery, and Psychiatry, 71, 493498.
Rinn, W.E. (1984). The neuropsychology of facial expression: A review of the neurological and psychological mechanisms for producing facial expressions. Psychological Bulletin, 95, 5277.
Sapir, S., Ramig, L.O., Fox, C.M. (2011). Intensive voice treatment in Parkinson's disease: Lee Silverman Voice Treatment. Expert Reviews in Neurotherapeutics, 11, 815830.
Sapir, S., Spielman, J.L., Ramig, L.O., Story, B.H., Fox, C. (2007). Effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on vowel articulation in dysarthric individuals with idiopathic Parkinson disease: Acoustic and perceptual findings. Journal of Speech, Language, and Hearing Research, 50, 899912.
Simons, G., Ellgring, H., Pasqualini, M.S. (2003). Disturbance of spontaneous and posed facial expressions in Parkinson's disease. Cognition and Emotion, 17, 759778.
Simons, G., Pasqualini, M.C.S., Reddy, V., Wood, J. (2004). Emotional and nonemotional facial expressions in people with Parkinson's disease. Journal of the International Neuropsychological Society, 10, 521535.
Smith, M.C., Smith, M.K., Ellgring, H. (1996). Spontaneous and posed facial expression in Parkinson's disease. Journal of the International Neuropsychological Society, 2, 383391.
Spielman, J.L., Borod, J.C., Ramig, L.O. (2003). The effects of intensive voice treatment on facial expressiveness in Parkinson disease: Preliminary data. Cognitive and Behavioral Neurology, 16, 177188.
Spielman, J. L., Dumer, A., Borod, J. C., Oster, J., Rabin, L. A., Halpern, A., Ramig, L. O. (2012, February). Impact of intensive treatment targeting loudness or articulation on facial and vocalexpression in Parkinson disease (PD). Paper presented at the 16th Biennial Conference on Motor Speech, Santa Rosa, CA.
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, 688700.
Stanley-Hermanns, M., Engebretson, J. (2010). Sailing the stormy seas: The illness experience of persons with Parkinson's disease. The Qualitative Report, 15, 340369. Retrieved from
Tickle-Degnen, L., Lyons, K.D. (2004). Practitioners’ impressions of patients with Parkinson's disease: The social ecology of the expressive mask. Social Science & Medicine, 58, 603614.
Tickle-Degnen, L., Zebrowitz, L.A., Ma, H. (2011). Culture, gender and health care stigma: Practitioners’ response to facial masking experienced by people with Parkinson's disease. Social Science & Medicine, 73, 95102.
Tripoliti, E., Strong, L., Hickey, F., Foltynie, T., Zrinzo, L., Candelario, J., Limousin, P. (2011). Treatment of dysarthria following subthalamic deep brain stimulation for Parkinson's disease. Movement Disorders, 26, 24342437.
Vaillancourt, D.E., Yu, H., Mayka, M.A., Corcos, D.M. (2007). Role of the basal ganglia and frontal cortex in selecting and producing internally guided force pulses. Neuroimage, 36, 793803.
Vallejo, G., Ato, M. (2012). Robust tests for multivariate factorial designs under heteroscedasticity. Behavior Research Methods, 44, 471489.
Wilcox, R.R. (2012). Introduction to robust estimation and hypothesis testing (3rd ed.). Oxford, England: Academic Press.
Wild, B., Rodden, F.A., Grodd, W., Ruch, W. (2003). Neural correlates of laugher and humor. Brain, 126, 21212138.


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Effects of the Lee Silverman Voice Treatment (LSVT® LOUD) on Hypomimia in Parkinson's Disease

  • Aleksey I. Dumer (a1) (a2), Harriet Oster (a3), David McCabe (a1) (a2), Laura A. Rabin (a2) (a4), Jennifer L. Spielman (a5), Lorraine O. Ramig (a5) (a6) and Joan C. Borod (a1) (a2) (a7)...


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