Voice Treatment for

Parkinson’s Disease
(LSVT LOUD):
Research Lab to
Global Implementation
Lorraine Ramig, Ph.D., CCC-SLP
National Center for Voice and Speech
University of Colorado, Boulder
Columbia University, New York City
LSVT Global, Inc., Tucson

NIH-NIDCD R01 DC-01150, R21 DC-006078, R21 NS-0437111, SBIR R43 DC-010956, SBIR R43 DC-
010498, SBIR R45 DC-010956, OE-NIDRR, Michael J. Fox Foundation, Davis Phinney Foundation,
Parkinson Alliance, Family of Lee Silverman
**ASHA Foundation YI
Disclosure
• Lorraine Ramig, PhD, CCC-SLP
• Professor, Senior Scientist, Adjunct Professor,
Co-Founder
• Relevant financial relationships:
• Receiving honorarium and travel/expense reimbursement
from the ASHA Foundation.
• Receives lecture honorarium and
• has ownership interest in LSVT Global, Inc.
• Relevant non-financial relationships:
• Preference for LSVT LOUD as a treatment technique and
equipment which will be discussed
 PLAN
• The Origin and Research Pathway
• The Implementation Pathway
“In the beginning…”
Challenges/Opportunities
Progress
Ingredients for Success
• Implementation today
Goals and Plans
Current Opportunities
• Perspectives
To improve human health,
scientific discoveries must
be translated into practical
applications.
-NIH
Parkinson disease (PD) is a
progressive, neurodegenerative
disorder with no known cure, which
effects nearly 6 million individuals
globally (e.g., de Lau & Breteler et al., 2006).
Over 89% of these individuals suffer
from voice and speech disorders.
Reduced vocal loudness, hoarse, monotone voice
and imprecise articulation (e.g., Logemann et al., 1978;
Sapir et al., 2001) are among the classic
characteristics.

These voice and speech disorders contribute to

lifelong frustration, embarrassment and social
isolation (e.g., Miller et al, 2006).
 Classic Medical Treatments Alone do not
Consistently or Significantly Improve Speech in
PD

Pharmacological Tx:
“…no evidence of systematic improvement in
dysarthria owing to dopamine replacement
therapy.” (e.g., Pinto et al, 2004)

Surgical Tx:
Neurosurgical interventions do not consistently
or effectively improve speech in PD ( e.g., Freed et
al., 1992; Goberman, 2005; Pinto et al., 2004; Rousseaux et al.,
2000; Tripoliti et al., 2008; Astromet et al., 2010)
Voice and Speech Disorders in PD have
been Historically Unresponsive to
Speech Treatment

Despite efforts to improve voice and

speech in PD (e.g., Sarno, 1968; Allan, 1970; Greene, 1980;
Weiner and Lang, 1980; Robertson and Thompson, 1984 ; Johnson and
Pring, 1990).

1987 no effective voice and speech

treatments for PD

‘If I have no voice, I have no life.’

-Natalie, individual with PD
 The Origin and Research Pathway
“if we could only hear and Federal & Foundation Funding –
understand her” over 20 years and 8 million dollars
–family of Lee Silverman

Phase I, II
1987-89: Initial invention; Pilot data
1989-91: Office of Education OE-NIDRR

1991-94: OE-NIDRR
1990-95: NIH funded RCT

Phase III
1995-00: NIH funded EMG
2002-07: NIH funded RCT
2007-12: NIH funded RCT

2001-02: Coleman Institute

Phase IV, V

2002-04: NIH and M J FOX Foundation

2002-04: Coleman Institute
2004-06: NIH R21
2004: Coleman Institute
2006: SBIR
2010: SBIR
 Conducted THREE Randomized Clinical Trials (RCT) to
Test
Efficacy of Treatments to improve Vocal Loudness
Among the first and most pervasive symptoms in PD (e.g., Logemann et al., 1978)
Respiratory (RESP) vs. voice (LSVT) (N=45)
Pre to post (Ramig et al., 1995) e.s. 1.81-1.20
Pre to 12 months follow-up (Ramig et al., 1996) e.s. .85-.65
Pre to 24 months follow-up (Ramig et al., 2001) e.s. 1.03-1.03

Voice (LSVT) vs. Untreated Control groups (PD, Healthy) (N=44)

Pre to Post to 6 months follow-up (Ramig et al., 2001)
e.s. 1.77-1.45, 1.50-1.03

Voice (LSVT) vs Articulation (ARTIC) vs Untreated Control groups (PD,

Healthy) (N=84) CONSORT
Pre to Post to 6 months follow-up (Ramig et al., 2014)
e.s. 1.63-2.03, 1.70-1.61
Average SPL effect size 1.23 (.65-1.81) Primary outcome variable
 Developed and established the efficacy of
voice treatment for Parkinson Disease
Pre to Post Pre to FU
Rainbow Monologue Rainbow Monologue
LSVT 2.03 1.63 1.70 1.61
ARTIC 0.59 0.45 0.32 0.33
UnTX 0.29 0.18 0.16 0.27

LSVT 1.81 1.20 0.85, 1.03* 0.65, 1.03*

RESP 0.82 0.67 0.06, 0.16* -0.64, 0.27*

LSVT 1.77 1.45 1.50 1.03

UnTX 0.08 0.03 0.08 0.03
*12, 24M

Since 1987, GOOD PROGRESS establishing efficacy of intensive voice treatment

Level 1 evidence
 Advances in Clinical Efficacy
(Ramig et al, 1995; 1996; 2001a; 2001b; Goetz, 2003)

Cross-system effects, Neural changes

P. Fox, Liotti Spielman, Borod (2003)

(2003) (facial expression)
Narayana
(2010)
(PET) Dromey, (1995) (articulation)

El-Sharkawi, Logemann
(2002)
(swallowing) Sapir (2007; 2010)
(articulatory acoustics)
Smith, M. (1995)
(adduction)
Smith,A.(2001) Taskoff (2001)
Ramig & Dromey (STI) (perceptual)
(1996) **patient and family
(aerodynamics)
Huber, Stathopoulos, (2003)
(respiratory kinematics)
Baker (1998),
Luschei (1999) (EMG)
 The Product:
Standardized Research-Based Behavioral Treatment Protocol

LSVT LOUD
Different than previous
Ramig et al. [87-88, 103]
Intensity: STANDARDIZED

speech treatment
Dosage: 4days/week for 4 weeks (16 sessions in one month)
Repetitions: Minimum 15 repetitions/task
*Effort: push for max patient-perceived effort each day (8 or 9 on scale of 1-10 with 10 being the most)
Simple Focus: LOUD
Increased movement amplitude directed predominately to respiratory/laryngeal systems

Single Target, Mode Daily Tasks: first half of the treatment session (25 minutes)
Task 1: Maximum sustained movements
(intensive, high effort), Calibration 15 reps: sustain “ah” in good quality, Loud voice as long as possible
Task 2: Directional movements
(in contrast) 15 reps each: say “ah” in Loud good quality voice going high in pitch;
15 reps each: say “ah” in Loud good quality voice going low in pitch
Task 3: Functional movements
Patient self-identifies 10 phrases or sentences he/she says daily in functional living (e.g., “Good morning”) 5
reps of the list of 10 phrases. “Read phrases using same effort/loudness as you did during the long ‘ah’”
Motor, Sensory and
Neuropsychological challenges Hierarchy: second half of the treatment session (25 minutes)

in PD -Designed to train rescaled amplitude/effort of movement achieved in CORE exercises from Daily Tasks into
in context specific and variable speaking activities
-Incorporate multiple repetitions with a focus on high effort (e.g., list of 20 phrases/sentences repeated 10
times for 200 repetitions)
-Tasks increase complexity across weeks (Words-phrases-sentences-reading-conversation) and can be

Grounded in principles of tailored to each subjects goals and interests (e.g., golf vs. cooking)
-Tasks progress in difficulty by increasing duration (maintain LOUD for longer periods of time) amplitude
(loudness - within normal limits), and complexity of tasks (dual processing, background noise and attentional
activity dependent neural distracters)

plasticity (exercise Sensory Calibration

Treatment: Focus attention on how it feels and sounds to talk LOUD

science), motor learning, Carryover activities: start day one; daily assignments (treatment and non-treatment days); use loud voice in
real life situations; - difficulty of the assignment matches the level of the hierarchy where the person is

muscle training working; make patient accountable and look for comments from patient that people in their daily living have
said, such as, “I can hear you better”
Homework practice: start day one: daily assignments to practice at home (Daily tasks and hierarchy
exercises); treatment days (one other time for 5-10 minutes); non-treatment days (two times for 10-15
minutes); homework book provided and patient made accountable
Video Example:
59 year old female
2.5 years post-diagnosis
On-meds pre and post video

Pre/post LSVT
(Lee Silverman Voice Treatment)
Intensive physical exercise of speech mechanism
“Ivory Tower”
Research Lab

Real World
“Clinical Trenches”
Patient Populations
LSVT Implementation Pathway: 1987-1996
The Situation The Approach The Opportunities

• 8 Million Parkinson’s Disease - • Traditional route: wrote a • Clinicians were implementing

89% degenerative speech problems guidebook only parts of the protocol

•We now have the first evidence •Conducted trainings in response •Risk was loss of treatment
that speech treatment can work to invitations fidelity “clinician delivery”
and last in PD
•Disseminated to patient and Approached Tech Transfer Office
•0% Awareness patients, physician groups through lectures (TTO) to help us protect protocol
clinicians, neurologists, healthcare to insure fidelity
professionals, PD
•TTO “didn’t want it”
•Conventional wisdom: “changes Behavioral treatment???
in the speech treatment room
in PD disappear on the way to If we had been a
the parking lot ” neuropharmacological
treatment…

•What to do?? “Developers make

poor disseminators…”
LSVT Implementation Pathway: 1997-2002
The Situation The Approach

Training
and
Certification
Workshop
1997
Trademarked name
internationally: LSVT Foundation • Clinicians adopted the protocol
because they saw impact on their
• Required Training and patients; evidence-based practice;
Certification for use of name LSVT underlying mechanism

Change Management Required! Medical community awareness;

No PAR “Rehabilitation revolution”
GAME Changer: Exercise science
• Standardized, evidence-based
therapy for PD was novel Demand for training and
treatment increased nationally
• Resistance to a standard and internationally
protocol (one size fits all?)
•Application to other disorders
• Intensive dosage in a “one time (MS, stroke, Cerebral palsy) (e.g.,
a week” world? Fox et al., 2012) SS, Small Gr

• Vocal hyperfunction (loud is •Development of LSVT BIG

vocal abuse!!) (Physical and Occupational
therapy) (e.g., Ebersbach et al.,
2010 RCT)
LSVT BIG clip
LSVT Implementation Pathway: 1997-2002
The Situation The Approach The Opportunity

Training
and
Certification
Workshop
1997

• LSVT Foundation: Trademarked • Clinicians adopted the protocol •Power of RX, Facilitate Growth
name internationally because they saw impact on their of Accessibility for patients and
patients; evidence-based practice clinicians GLOBALLY
• Required Training and •(one clinician can treat
Certification for use of name LSVT •Medical community awareness; 7/month, 6M individuals with
•“Rehabilitation revolution” PD…) SCALE; # clinicians
Change Management Required!
•Demand for training and •Technology supported training
• Standardized, evidence-based treatment increased nationally and treatment (e.g., Halpern et al.,
therapy for PD was novel and internationally; MD and 2011) LSVTCompanion software. FDA
patient lectures cleared.
• Resistance to a standard •Telemedicine (Theodoros et al., 2008)
protocol (one size fits all?) •Application to other disorders
(MS, stroke, Cerebral palsy) (e.g., •Sustainability and growth of entity
• Intensive dosage in a one time a Fox et al., 2011) that will outlast initial founders
week world?
•Development of LSVT BIG •What to do??
• Vocal hyperfunction (loud is (Physical and Occupational
vocal abuse!!) therapy) (e.g., Ebersbach et al., 2010)
LSVT Implementation Pathway: 2003-2009
The Situation The Approach The Opportunities

• Transitioned to a Business • Back to Tech Transfer Office • Under the leadership of TTO:
Model
•Entrepreneurial Center •CEOs
•Founded for-profit LSVT
Global •License technology from Universities •Legal teams
for LSVTCompanion and LSVT BIG
• Mechanism for software • Business plans
commercialization for LSVT •Submitted product and process
Companion patents • Investment pitches,

• Mechanism to to develop and

assess ONLINE Training and
Certification BUT…………
No success in the “shark tank”!

What to do?
LSVT Implementation Pathway: 2009-2014
The Situation The Approach The Opportunities

Organic growth business model SBIR Funding Harness clinician power globally;
effectiveness studies (are the
Maintain FIDELITY of training •Technology partners for LSVT treatments working in the ‘real world’?)
and treatments and increase Companion and ONLINE training
ACCESSIBILITY •Grow technology to support lifelong
• Offer clinician support: training and treatment (translations)
Need to do more than initial webinars, forums, online tools, •LSVT HYBRID, LOUD for LIFE and
training of clinicians, support renewal BIG for LIFE
their implementation;
Sustainability; research •Enhance Clinician database for •Partner Healthcare companies
advances access (Amedysis, Residential) and training
institutions (e.g., Columbia, Colorado,
Support patients lifelong
•www.lsvtglobal.com Rush, Purdue)
practice
Use research data to support
rehabilitation reimbursement

• Continued dissemination with

medical, professional and patient
communities
 LSVT Global EVOLUTION:
Using a successful business model to impact Fidelity and
Accessibility
Global Scalability
LSVT Global, Inc.

Information Dissemination and Training

LSVT Foundation, a 501c3 organization

Scientific Research Underlying Biobehavioral Treatments

National Center for Voice and Speech, over 8 million in NIH and other funding

‘87 ‘96 ‘97 ‘02 ‘03 ‘09 ‘14

Phase 1 Phase 2 Phase 3 Phase 4
LSVT Global: Impact in relation to our goal

Change Management:
Getting the rehabilitation
professional communities
to embrace a new way of
delivering treatment

Awareness: Accessibility:
Educate Medical, Increase access to
Professional, and training and treatment
Patient Communities through technology
 LSVT® LOUD global standard for Speech Treatment
for PD (Pinto et al., 2004) NICE Great Britain

Maintain Treatment Fidelity:

Global Standardized Treatment “LSVT is LSVT is LSVT”
Standardized Training
 Summary of Progress
• Training (0) • Treatment (0)
• 15,000 trained • Estimate 150,000
• 54 countries treated globally
• Online training • LSVT Companion
FDA (German)
• Renewal
• LSVT Telepractice
• Webinars (module)

• Modules • LSVT-Hybrid
• Sustain and • LOUD BIG for LIFE
enhance • Beyond PD
fidelity “life long”
 Summary of Progress
• LSVT administered in medical centers, university clinics,
private practice, healthcare networks

• Successful Implementation?
Amedysis quote “So prior to LSVT we had 0% NOMS FCM Voice
Progress. At the close of 2013 we had FCM Voice Progress
Numbers of 61.54%”.
OpenlinesNYC Communication quote “97.42% of PD
demonstrated improved SPL (loudness) in speech; 87.53% had
lower total VHI (Voice Handicap) scores, and all people reported
an improvement in voice. All patients and families reported
functional voice improvement, reduced communication
breakdowns, and greater QOL in both the patients and their
caregivers' lives.’’
 Ingredients for using a Business Model for
Implementation
Team
• Rock Solid product
• Thick skin
• Identify gate keepers
• Focus on first adopters
• Span research and treatment
• Ever evolve
Essential to have a ‘Fundamental Passion’ for the vision JOY!
Fueled by seeing the direct impact on patients lives
Clinicians ‘EMPOWERED’ by delivering efficacious
treatment
Impact on the fields of neurology and rehabilitation
‘taking rehabilitation seriously’
 Perspectives Gained and Lessons Learned

This world is not for “the faint of heart”

Change management, translating research

treatment to real world ‘scope of practice’ requires
seeing the ‘world though many eyes’ Open your mind
and be persistent!

Recognize your competence

‘trust yourself’

“you need to be surrounded by good advisors

but you also have to trust your instinct”
Chris Hughes Co-Founder Facebook
 Perspectives Gained and Lessons Learned

• “Don’t stop believing”

-Journey

Our field is rich with potential to

dramatically improve quality of life.
To a patient……major life impact

“My voice is alive again”

“I can talk to my grandchildren!”
“I feel like my old self”
“LSVT BIG has changed my life…the
impact is beyond a miracle!”
“I am confident I can communicate!”
Ramig, L., Sapir, S., Countryman, S., Pawlas, A., O’Brien, C., Hoehn, M.,
Thompson, L. (2001). Intensive voice treatment (LSVT) for individuals with
Parkinson disease: a two year follow-up. J, Neurology, Neurosurgery and
Psychiatry, 71, 493-498.

Ramig, L., Sapir, S., Fox, C., & Countryman, S. (2001). Changes in vocal
intensity following intensive voice treatment (LSVT) in individuals with
Parkinson disease: a comparison with untreated patients and normal age-
matched controls. Movement Disorders, 16, 79-83.

Sapir, S., Ramig, L., Fox, C. (2011). Intensive voice treatment in

Parkinson’s disease: Lee Silverman Voice Treatment (LSVT). Expert
Reviews in Neurotherapeutics, 11(6), 815-810.

Liotti, M., Vogel, D., Ramig, L., New, P., Cook, C., Ingham, R., Ingham, J., &
Fox, P. (2003). Hypophonia in Parkinson’s disease: neural correlation of
voice treatment revealed by PET. Neurology, 60, 432-440.
Narayana, S., Fox, P., Zhang, W., Franklin, C., Robin, D., Vogel, D., Ramig,
L. (2010). Neural correlates of efficacy of voice therapy in Parkinson’s
disease identified by performance-correlation analysis. Human Brain
Mapping, 31, 222-236.

Fox, C., & Boliek, C. (2012). Intensive voice treatment (LSVT LOUD) for
children with spastic cerebral palsy and dysarthria. J. Speech Language
Hearing Research,. 55, 930-945.

Ebersbach, G., Ebersbach, A., Edler, D., Kaufhold, O., Kusch, M., Kupush,
A., & Wissel, J. (2010). Comparing exercise in Parkinson’s disease-the
Berlin LSVT®BIG study. Movement Disorders, 25 (12): 1902-1908.

Halpern, A., Ramig, L., Matos, C., Petska-Cable, J., Spielman, J., Pogoda, J.,
Gilley, P., Sapir, S., Bennett, J., McFarland, D. (2012). Innovative technology
for the assisted delivery of intensive voice treatment (LSVT®LOUD) for
Parkinson disease. Am. J. Speech-Language Pathology, 21 (4), 354-367.
 Implementation process today:
Goals and Plans
• 1) Scale
• Training and access to treatment
• Partner with organizations, training institutions, medical
networks
• --bottom up “grassroots” top down
• Application to other disorders (e.g., MS, stroke, CP, Downs)
273M need lifelong intervention
• LSVT BIG

• 2) Follow-up driven by exercise science

• LOUD for LIFE, BIG for LIFE
 Comparing Exercise in Parkinson’s Disease —
The Berlin LSVT BIG Study (2010, Movement Disorders)
Georg Ebersbach, * Almut Ebersbach, Daniela Edler, Olaf Kaufhold, Matthias Kusch,
1 1 1 1 1

Andreas Kupsch, and Jo¨rg Wissel

2

UPDRS motor score (blinded rating), mean change from baseline (vertical bars 5 standard deviations). Change between
baseline and follow up at week 16 was superior in BIG (interrupted line) compared to WALK (dotted line) and HOME
(solid line), P <0.001. ANCOVA did not disclose significant differences between in intermediate and final assessments.
 Our Implementation Pathway
2014 Progress:

• _____ LSVT LOUD Clinicians in ______ countries

LSVT LOUD Training materials in ____ languages
In addition…
• _____ Online LSVT LOUD Training
• _____ Online LSVT LOUD Renewal
_____ Webinars, listserv, Expert hotline
Is the treatment effective (working in the real world?)
DATA from Amedysis, other?
• ____ patients globally receive LSVT LOUD
• ______ website database of XXX LSVT LOUD clinicians

Add numbers of clinicians who participated

Other stuff: clinicians are taught the published research in PD and outcome data, given dissemination materials
As a part of every workshop patient lecture and practice session XX number of patients globally
MDs refer clinicians globally!!
Quotes from clinicians? Pride about delivering evidence based practice
Value to their community and company
 LSVT Global, Inc. IP
Trademarks: words, names, symbols distinguish goods

– LSVT ®
– LSVT COMPANION®
– LSVT BIG™
– LSVT LOUD™
– (US, EU, AU, BR, CA, CH, JP, SG, WO)

Copyrights: works of expression, granted for originality

– LSVT Training and Certification Workshop Binders and Lectures

– Patient Presentation
– LSVT BIG and LSVT LOUD Marketing Brochures
– LSVT LOUD Patient Assessment and Treatment Pack
– LSVT WEBSITE
 LSVT Global, Inc. IP
Patent:
– LSVT® HYBRID
– SPL calibration

Licenses:
– University of Arizona, University of Colorado
– All LSVT LOUD and LSVT BIG Certified clinicians globally
– Healthcare Organizations: HealthSouth, Amedysis

Regulatory affairs:
FDA Clearance (510K)
CE EU
AU, NZ, CA
- LSVT Companion Software
 LSVT LOUD Applications
• Parkinson Plus (Countryman et al., 1994)
• Post Surgery, Fetal cell (Countryman, et al., 1993)
• Stroke (Fox et al, 2002; Mahler et al., 2009)
• Multiple Sclerosis (Sapir et al., 2001)
• Ataxia (Sapir et al., 2003)
• Cerebral palsy (Fox et al, in press)
• Down Syndrome (Robinson et al., 2004; Petska et al, 2006)
• Aging (Ramig et al., 2001)
 TARGET
Loud is more than a laryngeal event
– spread of effects

LOUD

SOFT
HEALTHY LOUDNESS
Neural coupling (McClean and Tasko)
20+ year journey from invention to scale-up
Phase I, II
1987-89: Initial invention; Pilot data (Scottsdale)
Development
1989-91: Office of Education OE-NIDRR

1991-94: OE-NIDRR
1990-95: NIH funded RCT Efficacy
Phase III

1995-00: NIH funded EMG, Kinematics

Efficacy
2002-07: NIH funded RCT Spread of effects
2007-12: NIH funded RCT, imaging

2001-02: Coleman Institute (PDA; LSVTC)

2002-04: NIH and M J FOX Foundation PDA (R21)
2002-04: Coleman Institute (VT; LSVTVT)
Phase IV, V

2004-06: NIH LSVTVT (R21)

Clinician Training & Treatment
2004 : Coleman Institute (LSVT Down Syndrome)
Accessibility
2004-07: LSVT –Dissemination
2006: Technology-enhanced Clinician Training (SBIR)
2010: Technology-enhanced LSVT LOUD delivery
(SBIR)
 Moderate/severe Voice/speech Mild/moderate speech
speech disorder
Difficulty shaping good evaluation by speech- disorder
Easily shaped good
voice quality language pathologist voice quality
Moderate/severe
cognitive impairment Mild to no cognitive
Visually impaired impairment

Face-to-Face Technology assisted

treatment with LSVT LSVT LOUD treatment
LOUD Certified LSVT Companion (LSVTC)
Funded R21 DC 05583
Clinician

Live in the clinic Live Telehealth Independent

Live in the clinic Live telehealth delivery with delivery with use of LSVTC
delivery of delivery of LSVTC LSVTC
(All sessions
treatment treatment independent
(Half sessions in (Half sessions
clinic/half sessions telehealth/half practice at
(LSVTC as data (LSVTC as data
independent sessions home, with or
collection tool only) collection tool only)
practice at home) independent without clinician
Funded R21 DC 05583 practice at home) monitoring )

Follow-up/ maintenance
Independent use of LSVTC
with clinician monitoring
 We have been chipping away for twenty years…

Today LSVT® LOUD has Level 1 evidence for speech

treatment for Parkinson disease, is being delivered in
over 50 countries and has been endorsed by the
National Institute of Clinical Excellence (NICE) in
Great Britain.
 LSVT Global, Inc. Products
emerged from core LSVT protocol and supported by
outcome data
• Training
• In person training LSVT LOUD, LSVT BIG (Physical therapy)
• Online LSVT LOUD training
• Online Renewal
• Online training modules

• Treatment
• LSVT LOUD standard protocol
• LSVT BIG standard protocol
• LSVT Hybrid standard protocol
• LSVTCompanion software**
• LSVTeLOUD** telepractice delivery
• LSVT Homework Helper
LSVT eLOUD LSVT Companion
Telepractice Funded by: NIH-NIDCD &
(Theodoros et al, 2006) Michael J. Fox Foundation
Perceptive, independent
50% of sessions delivered by LSVTCOMPANION (p< 0.001) n=16

90.0

85.0

80.0

Pre
dB

75.0 Post
FU

70.0

65.0

60.0
Sustained Monologue Rainbow Cognitive
Phonation Passage Task

Changes consistent with those reported in previously

published data (Halpern et al, 2011)