Short-term effects of "Yijinjing Wohu Pushi" posture-voice therapy on speech in Parkinson's disease after STN-DBS

Short-term effects of "Yijinjing Wohu Pushi" posture-voice therapy on speech in Parkinson's disease after STN-DBS | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Short-term effects of "Yijinjing Wohu Pushi" posture-voice therapy on speech in Parkinson's disease after STN-DBS xin sun, Mei Yang, Jin Yan, Linbin Wang, Yuxin Sun, Yong Wang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3977487/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Hypokinetic dysarthria in Parkinson's Disease (HD-PD) deteriorates patients' quality of life by impeding communication and social engagement. Existing treatments like levodopa drugs and deep brain stimulation (DBS) can improve motor symptoms but fall short in addressing speech-related impairments; effective speech therapies tend not to mandate the posture, which potentially hinders vocal performance. Here we first proposed a therapeutic protocol that specified a lunging-and-clawing posture (Wohu Pushi method from Yijinjing) during vocalization training. The protocol aimed to ensure that PD patients could accomplish the training even with moderate motor impairments. A total of 20 HD-PD patients with implanted stimulators in subthalamic nuclei (STN-DBS) participated in one session of training, either following our posture-voice therapy (PVT) or the conventional voice therapy (CVT). Results indicated that the maximum phonation time was significantly elongated in PVT(3.85±2.81s) but not in CVT(0.46±2.24s), and the formant-distance was significantly increased in PVT(95.80±112.71Hz) compare to CVT(-47.10±84.28Hz). Our results indicated that by demanding appropriate amount of postural maintenance during vocalization, it might facilitate the recovery of speech-related functions. This study warranted larger-scale clinical trials to understand the impact, limitation, and optimization of posture-voice therapy for HD-PD. Parkinson’s disease rehabilitation vocalization posture deep brain stimulation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 1 Introduction Hypokinetic dysarthria (HD) is a speech disorder unique to patients with Parkinson’s disease (PD)[1]. HD-PD traumatizes the overall quality of life with PD due to impaired communication and social participation[2], which tend to gradually deteriorate to the point of complete refusal to communicate[3]. Although both levodopa drugs and deep brain stimulation (DBS) have been proven to improve motor symptoms in patients with PD, neither has shown significant therapeutic effects on speech-related impairments[4], [5]. Successful production of speech depends on a coordinated interplay among respiration, phonation, articulation, resonance, prosody, etc.[6]. Therefore, direct training on these activities have been explicitly studied and administered in rehabilitation clinic for HD-PD[7]. For example, phonation was instrumental in LSVT LOUD[8], a widely tested and accepted therapeutic regime[9]. Respiration is emphasized in Respiratory Muscle Strength Training (RMST), where improvement in the patient's respiratory muscle strength may result in a greater flow of air to stimulate voice production[10]. Prosody is a key component of the SPEAK-OUT training program, thereby improving monopitch in patients with PD[11]. In addition, posture and movement were also considered important in the selection of therapy goals for the elicitation of better voicing[12]. However, most of the existing therapies imposed minimal, if not none, requirements on how postures should be maintained during vocalization. Incorrect posture and body movements could hinder the recovery of vocalization and even the overall axial symptoms [13], [14]. In specific, a posture with improper alignment of the body tends to facilitate the voice production, due to the excessive the energy expenditure and strain on tissues[15], [16]. Another postural abnormality found commonly with PD is with neck flexion[14]. The soft tissue of the throat and the muscles that raise the larynx can alter due to imbalances in the neck and head, which can affect voice control and resonance [16]. Therefore, therapeutic exercise with postural correction may provide addition benefits for voice production in PD. For instance, Yijinjing is a type of traditional Chinese exercise with explicit emphasis on the coordination of posture, which has been proven to alleviate joint pain[17], increase muscle strength, and improve balance[18]. The ninth method of Yijinjing – "Wohu Pushi (a crouching tiger to pounce for food)" – describes a posture-voice exercise. The Wohu Pushi method asks the trainee to imitate a crouching tiger by assuming a lunging-and-clawing posture, and it trains the voice production by imitation of a tiger’s roaring[19]. In this study, we added posture maintenance to a conventional voice therapy conforming with LSVT LOUD principles. We present a protocol of posture-voice therapy that PD patients with mild to moderate motor impairments could still participate. Using this protocol, we also examined the posture-voice therapy on speech function in PD patients who received deep-brain stimulation in subthalamic nuclei (STN-DBS). The posture-voice therapy was tested in comparison with the conventional voice therapy, both of which incorporated similar voice exercises but they differed in requirements on posture. Objective measures on acoustic and speech performances were acquired and analyzed. Our main hypothesis was that the posture-voice therapy would incur discernable short-term changes after one session of training. If proven, this study would provide support for a series of experiments to identify the longer-term clinical benefits of posture-voice therapy as well as its neurological mechanisms. 2 Methods We designed a prospective study to compare speech improvement before and after training in patients with conventional voice therapy (CVT) or posture-voice therapy (PVT). The CVT was derived following LSVT LOUD principles with essential adaptations (Fig.1A), which ensured that the repetition, content, and perceived effort of voice training were similar between groups. We modified the conventional therapy inspired from the ninth method “Wohu Pushi” of Yijinjing, a traditional Chinese exercise (Fig. 1B). By requiring a lunging-and-clawing posture during the conventional voice therapy, the participants received posture-voice therapy in the PVT group (Fig. 1C). Details of CVT and PVT are specified below. 2.1 Training protocols In both groups, participants were required to accomplish 3 tasks of phonation specified below. Tone-up (TU)：The vowel /ɑ/ is pronounced from low pitch to high pitch, with the entire pronunciation process lasting more than 10 seconds and maintaining a slight hold at the highest pitch. Maximum sustained movements (MS): Prolong the vowel /ɑ/ as much as possible while maintaining vowel pronunciation at 70% of your maximum SPL. Tone-down (TD): The vowel /ɑ/ is pronounced from high pitch to low pitch, with the entire pronunciation process lasting more than 10 seconds and maintaining a slight hold at the lowest pitch. The primary differences between groups were with the posture maintenance during phonation tasks. The CVT group, the participant performed the above phonation tasks while remaining seated in the chair throughout the vocalization training. In the PVT group, the key requirement was the maintenance of a lunging-and-clawing posture during voice production. The lunging required that the participant started with a stance at shoulder-width, and lunged to keep the forward thigh horizontal. The forward knee should align with the toe. The behind leg should be extended straight. Meanwhile the trunk should stay upright. The clawing required that the participant started with their hands shoulder-width apart, fingers spread, with the fingertips pressing against the tabletop. The elbows should be straight, shoulders relaxed, and chest raised. During vocalization, the cervical spine should be extended backward and the mouth opened as wide as possible. The experimenter helped the participant adjust the height of the table to the lowest clearance without losing stability. The sequence of trials in both groups are listed in (Fig. 2). Each participant, either in the PVT or CVT group, accomplished 48 repetitions of vocalization tasks. Verbal feedback and encouragement were given to the participant after each trial of vocalization. Rests were given ad-hoc between trials as required by the participants. 1.1 Study Design Participants were recruited from February to June 2023 from the outpatient Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. The inclusion criteria were: (1) More than 6 months after bilateral STN-DBS surgery for PD; (2) No adjustments to medication or DBS stimulation parameters in the past 3 months; (3) VHI-10＞11 [20]; (4) Within Stages Ⅰto Ⅳ on the Hoehn Yahr scale[21]; (5) No significant cognitive impairment (MMSE⩾25)[22]; (6) Age 18 and above; (7) Native Chinese speaker. The exclusion criteria were: (1) Diagnosed previously or currently with diseases that affect swallowing function (such as vocal nodules, gastroesophageal reflux, laryngeal cancer, and other laryngeal diseases); (2) Having difficulty breathing, fever, lung infection or chronic lung disease, or abnormal oral structure; (3) Due to various other reasons, the training tasks required for this study cannot be completed. Allocation of participants into groups was accomplished using a computer program with random number generation (Fig. 3A). All PD participants were on levodopa medication with daily routine of dosage. Each patient underwent a speech assessment, followed by the phonation exercise as required by the allocated group. Immediately after training, another speech assessment was carried out. Each participant practiced 5-10 trials of phonation (either TD/MS/TU) as a familiarization to the protocol. The entire visit took approximately 1.5 hours (Fig. 3B). All participants gave written consent as approved by the Ethics Committee of Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University (No. 224 of 2022). The training was administered by certified inheritors of Yijinjing (The National List of Intangible Cultural Heritage of China, Project No. IX-2) and licensed LSVT-LOUD therapists (ONLOUDCH1121-52, 0822-18, 0822-19, 1122-04). 1.2 Data Acquisition Speech recordings were performed in a quiet room with a low ambient noise level using a condenser microphone placed approximately 30 cm from the subject’s mouth (Fig. 4). Speech signals were sampled at 48 kHz with 16-bit resolution. Our acoustic indicators including MPT, DSI, SPL/ɑ/, SPL"Reading", DDK rate, and vowel production(/ɑ/,/i/,/u/), collected through the following acoustic tasks[23]–[26]. Maximum phonation time (MPT, in seconds) – take a deep breath, and sustain the vowel "ah" as long as possible, record the longest phonation out of three measures as MPT; Fundamental frequency (F 0 , in Hz) - maintain a comfortable volume and a consistent tone while sustaining the vowel sound /ɑ/ for more than 3 seconds; Highest frequency (F 0 -High, in Hz) - gradually increase the tone of "ah" from normal speaking to the highest point and sustain it for 1-2 seconds; Lowest intensity (I-Low, in dB) - Start at a normal volume, sound "ah", and gradually decrease the volume; Diadochokinetic rate (DDK rate, in syllables per second) - produce the syllables /pa/, /ta/, and /ka/ as quickly as possible for as long as you can; Vowel production - pronounce the vowels /ɑ/, /i/, and /u/ as smoothly and comfortably as possible, maintaining the sound for more than 3 seconds; SPL/ɑ/ (in dB) - acoustic record reference fundamental frequency; SPL"Reading" (in dB) - read the story of "The North Wind and the Sun" at a comfortable pitch and loudness, as if you are having a regular conversation. (Figure. 4 is omitted due to exposure of patient images; the figure is available upon request to the corresponding authors.) Figure. 4. Actual scenes of therapeutic training and assessments. A) A participant performing “Wohu Pushi” posture-voice therapy. The participant performed vocal exercises by leaning with both hands on a height-adjustable table, maintaining a lunging-and-clawing posture. B) the acoustic assessment of participants using lingWAVES. Participants vocalized facing a microphone, while an experimentalist recorded the acoustic parameters of voice. Using the PRAAT software, select the formant one frequency F1 and the formant two frequency F2 for the vowels /ɑ/, /i/, and /u/ respectively. The software LingWAVES (Software Version 3.2, Wevosys) was used for voice measurements. Analyze the acoustic data of the participants using PRAAT (version 6.3.08) software. 1.3 Outcome measures and statistical analysis The primary outcome measure in this study was ΔMPT , defined as the difference in maximum phonation time before and after the training. Another outcome measure was the formant-distance, defined as the frequency difference between the formant one of /ɑ/ and , i.e. [27]. The third outcome measure was the vector-similarity between the participant-pronounced vector and the group-averaged vector, which was calculated based on the one and two formants of each vowel. Since the first two formants of vowel formed a 2-dimensional vector on the frequency plane [28], we were interested in the similarity between the participant-pronounced vector and the group-averaged vector. This outcome measure aimed to quantify whether a participant showed congruent changes compared to his/her group trend. It was calculated as follows: Statistical analyses were conducted using R (version 4.3.0). Between-group comparisons were conducted either using Welch’s t-test, or by a two-way repeated-measure analysis of variance (RM-ANOVA) with factors of GROUP (PVT vs. CVT) and EVALUATION (before training, after training) formulated as follows: 3 Results 3.1 Baseline characteristics of the participants We screened 42 candidates who agreed to participate. A total of 20 participants finished the study, with 10 in the PVT group (3 male and 7 females, age 62.3 ± 9.29) and 10 in the CVT group (6 male and 4 females, age 65.9 ± 5.42). No statistical differences were found between groups in age, sex, months since diagnosis, months since surgery, Hoehn-Yahr (HY) scale, Unified Parkinson’s Disease Rating Scale III (UPDRS III), or Voice Handicap Index-10 (VHI-10) (Table 1 ). Refer to the supplementary materials for details about the stimulation setting. Table 1 Baseline characteristics of the participants Variable PVT group CVT group P-value Number 10 10 Age, y* 62.3 ± 9.29 65.9 ± 5.42 0.307 Sex, M/F # 3/7 6/4 0.369 Months since diagnosis* 136.2 ± 61.51 165.6 ± 64.6 0.311 Months since surgery* 28.2 ± 27.86 18 ± 21.35 0.371 HY scale* 2.7 ± 0.78 2.75 ± 0.35 0.857 UPDRS III score* 32.3 ± 18.2 25.6 ± 10.63 0.332 VHI-10 score* 23.7 ± 3.26 24.0 ± 3.85 0.853 #Based on the Fisher's exact test. * Group means compared using Welch’s t-test. M, male; F, female; HY, Hoehn–Yahr scale; UPDRS III, Unified Parkinson’s Disease Rating Scale III; VHI-10, Voice Handicap Index-10. 3.2 Maximum phonation time Voice time series of /ɑ/ pronunciation from representative participants in each group are shown in Fig. 5 . As can be seen, Subject09 in the PVT group performed with an increase in MPT after training, while Subject107 in the CVT group also had an increase in MPT, but the change was smaller. Pooled data suggest that the PVT group exhibited an overall increasing trend in MPT scores post-intervention (Fig. 6 A), while the CVT group showed inconsistent MPT changes among participants (Fig. 6 B). A 2×2 two-way repeated-measures ANOVA (Fig. 6 C) indicated a significant main effect of EVALUATION on MPT (F 1,18 =14.305, p < 0.01). No significant main effect for GROUP (F 1,18 = 0.064, p = 0.803) was found. The interaction between GROUP and EVALUATION was significant (F 1,18 =8.843, p < 0.01), suggesting that the PVT and CVT groups differed in MPT score changes over time. Post-hoc comparison with the Tukey test showed a significant increase in MPT for the PVT group from "Before" to "After" (p < 0.001), but the changes were non-significant in the CVT group (p = 0.939). 3.3 Vowel production We plotted the vector change graph on a two-dimensional plane, with the starting and ending points of the vector being the formant frequency before and after training, respectively(Fig. 7 )[ 28 ]. Pooled data suggest that the PVT group exhibited an overall increasing trend in formant-distance (∆F1) after the therapy (Fig. 8 A), while the majority of participants in CVT group showed a decline (Fig. 8 B). A 2×2 two-way repeated-measures ANOVA (Fig. 6 C) indicated no significant main effect of GROUP on ∆F1 (F 1,18 = 2.856, p = 0.108) or main effect of EVALUATION (F 1,18 = 1.436, p = 0.246). However, the interaction between EVALUATION and GROUP was significant (F 1,18 = 12.362, p < 0.01). Post-hoc comparison with the Tukey test showed a significant increase in ∆F1 within the PVT group (p < 0.05) but not in CVT group (p = 0.383). The vector-similarity \(d\left({v}_{i}\right)\) between the individual vectors and group-averaged vectors was analyzed. Welch’s t-test showed that for the vowel /ɑ/, the vector-similarity in PVT group was larger compared to that in CVT group (t 9.842 = 3.165, p < 0.05, Fig. 9 A); Welch’s t-test was chosen because it allowed for comparisons between groups that did not confirm homoscedasticity. For the vowel /i/, the vector-similarity was smaller in PVT compared to CVT (t 9.181 =-2.691, p < 0.05, Fig. 9 B). Vowel /u/ showed no significant changes between groups (t 18 = 0.857, p = 0.402, Fig. 9 C). 3.4 DSI, SPL, DDK rate For other acoustic measures, we did not detect any significant main effects of GROUP or EVALUATION (Fig. 10 ), and no significant interactions were found. 3.5 Correlation betweenΔMPT and other factors Due to the significant improvement shown by MPT in the results, we continued to explore whether changes in MPT ( \({\Delta }\text{M}\text{P}\text{T}\) ) could be explained by known clinical profiles of participants. Linear regressions showed a significant correlation between \({\Delta }\text{M}\text{P}\text{T}\) and the months-since-diagnosis, i.e. the longer months since diagnosis, the more significant the improvement in MPT after one training session. The linear relationship is \(\text{y}=0.026\text{x}+0.372\) (one-tailed p<0.05, R 2 = 0.311, Fig. 11 ). \({\Delta }\text{M}\text{P}\text{T}\) was not significantly correlated with UPDRS III or VHI-10. 4 Discussion This study developed a protocol for conducting voice training for PD patients after STN-DBS. The protocol specified that a lunging-and-clawing posture should be maintained during vocalization. A pilot study was conducted to examine the short-term benefit of posture-voice therapy compared with conventional voice therapy that did not impose posture requirements. Results showed that after one session of training, the posture-voice therapy (PVT) managed to elongate the maximum phonation time and the formant-distance better than the conventional voice therapy (CVT). Our results suggested more prominent improvements if the patients received longer periods of "Wohu Pushi" posture-voice therapy. This short-term protocol was not sensitive enough to detect significant changes in acoustic measures including DSI, SPL, and DDK rate. Overall, our results indicated that adding posture requirements to conventional voice therapy for PD patients could facilitate recovery on voice and speech production. One reason why posture-voice therapy elongated MPT more than did the conventional voice therapy, is that MPT associates with the respiratory capacity during speech production[ 10 ]. By assuming the typical "Wohu Pushi”posture, subjects may have learned to inspire to a higher percentage of their vital capacities, due to the stretching of the respiratory muscles (including the intercostal muscles, the sternocleidomastoid muscles and pectoralis major muscles), thereby increasing the amount of available air stream used for phonation. It is noteworthy that the formant-distance in PVT group was larger than that in CVT group, even though both groups emphasized on keeping the mouth open during training. Formant-distance is a quantitative measure of the acoustic form of the degree of mouth opening, which is generally proportional to the quality of the pronunciation[ 30 ], [ 31 ]. The repeated flexion and extension of the cervical spine during training in the PVT group may stimulate the proprioception of the relevant muscles in the jaw, thereby improving the sensory processing of the jaw. Our current experimental setup did not allow us to differentiate the contribution between leg lunging and hand supporting. Although this study demonstrates that overall postural vocalization can improve certain acoustic indicators, whether the upper or lower limbs contribute more to vocalization, allowing us to optimize it more in the future, remains to be further investigated. In conclusion, this pilot study suggests that by requiring adequate posture maintenance in a conventional voice therapy, we have developed a clinically viable protocol that PD patients with STN-DBS could accomplish even with mild to moderate motor impairments. The posture-voice therapy is likely more effective in improving MPT and formant-distance compared to the conventional voice therapy. Abbreviations CVT conventional voice therapy DBS deep brain stimulation DDK diadochokinetic DSI dysphonia severity index HD hypokinetic dysarthria HY Hoehn-Yahr scale LSVT Lee Silverman Voice Therapy MMSE mini-mental state examination MPT maximum phonation time MS maximum sustained movements PD Parkinson’s disease PVT posture-voice therapy RMST Respiratory Muscle Strength Training RM-ANOVA repeated-measures analysis of variance SPL sound pressure level STN subthalamic nucleus TD tone-down TU tone-up UPDRS Unified Parkinson’s Disease Rating Scale VHI Voice Handicap Index Declarations Author Contributions: Conceptualization, C.M.N. and D.Y.L.; formal analysis, X.S. and Y.X.S; funding acquisition, D.Y.L. and C.M.N.; investigation, X.S. and J.Y.; methodology, X.S., M.Y., J.Y., and C.M.N.; project administration, D.Y.L. and C.M.N.; resources, D.Y.L.; supervision, S.Q.Y. and Y.W.; writing—original draft, X.S.; writing—review and editing, L.B.W, D.Y.L., and C.M.N. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded by "Shanghai General Hospital Integrated Traditional Chinese and Western Medicine Special Project" grant number: ZHYY-ZXYJHZX-202103. "Shanghai STC International Science and Technology Cooperation Project" grant number:22490711000. Institutional Review Board Statement: This study was approved by the Ethics Committee of Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University (no. 224 of 2022). Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Acknowledgments: The authors thank Ms. Lu Xu for her assistance with patient recruitment and baseline assessment. We also thank Mr. Qiang Xu from RJH-FFTAI Joint Laboratory for development of essential software to facilitate the study. Conflicts of Interest: The authors declare no conflict of interest. References Pinto S, Ozsancak C, Tripoliti E, Thobois S, Auzou P (2004) Treatments for dysarthria in Parkinson’s disease. Lancet Neurol 3(9):547–556 Miller N, Noble E, Jones D, Burn D (May 2006) Life with communication changes in Parkinson’s disease. Age Ageing 35(3):235–239. 10.1093/ageing/afj053 Schalling E, Johansson K, Hartelius L (2017) Speech and Communication Changes Reported by People with Parkinson’s Disease. Folia Phoniatr Logop 69(3):131–141. 10.1159/000479927 Hariz M, Blomstedt P (2022) Deep brain stimulation for Parkinson’s disease, J Intern Med , vol. 292, no. 5, pp. 764–778, Nov. 10.1111/joim.13541 Tykalová T et al (2015) Aug., Effect of dopaminergic medication on speech dysfluency in Parkinson’s disease: a longitudinal study, J Neural Transm , vol. 122, no. 8, pp. 1135–1142, 10.1007/s00702-015-1363-y Yorkston KM (Oct. 1996) Treatment Efficacy: Dysarthria. J Speech Lang Hear Res 39(5). 10.1044/jshr.3905.s46 Herd CP et al (2012) Aug., Comparison of speech and language therapy techniques for speech problems in Parkinson’s disease, Cochrane Database of Systematic Reviews , 10.1002/14651858.CD002814.pub2 Ramig L, Halpern A, Spielman J, Fox C, Freeman K (2018) Speech treatment in Parkinson’s disease: Randomized controlled trial (RCT): SPEECH TREATMENT IN PARKINSON’S DISEASE: RCT, Mov Disord. , vol. 33, no. 11, pp. 1777–1791, Nov. 10.1002/mds.27460 Mahler LA, Ramig LO, Fox C (2015) Evidence-based treatment of voice and speech disorders in Parkinson disease:, Current Opinion in Otolaryngology & Head and Neck Surgery , vol. 23, no. 3, pp. 209–215, Jun. 10.1097/MOO.0000000000000151 Zhuang J, Jia J (Jun. 2022) Effects of Respiratory Muscle Strength Training on Respiratory-Related Impairments of Parkinson’s Disease. Front Aging Neurosci 14:929923. 10.3389/fnagi.2022.929923 Boutsen FR, Park E, Dvorak JD (2023) An Efficacy Study of Voice Quality Using Cepstral Analyses of Phonation in Parkinson’s Disease before and after SPEAK-OUT!®. Folia Phoniatr Logop 75(1):35–42. 10.1159/000525884 Behrman A (Sep. 2005) Common Practices of Voice Therapists in the Evaluation of Patients. J Voice 19(3):454–469. 10.1016/j.jvoice.2004.08.004 Angsuwarangsee T, Morrison M (Sep. 2002) Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders. J Voice 16(3):333–343. 10.1016/S0892-1997(02)00105-4 Yoshii F, Moriya Y, Ohnuki T, Ryo M, Takahashi W (Dec. 2016) Postural deformities in Parkinson’s disease –Mutual relationships among neck flexion, fore-bent, knee-bent and lateral-bent angles and correlations with clinical predictors. J Clin Mov Disord 3(1):1. 10.1186/s40734-016-0029-8 Arboleda BMW, Frederick AL (2008) Considerations for maintenance of postural alignment for voice production. J Voice 22(1):90–99 Cardoso R, Lumini-Oliveira J, Meneses RF (2019) Associations between Posture, Voice, and Dysphonia: A Systematic Review, Journal of Voice , vol. 33, no. 1, p. 124.e1-124.e12, Jan. 10.1016/j.jvoice.2017.08.030 Cheng Z et al (Dec. 2022) Effectiveness of Tuina Therapy Combined With Yijinjing Exercise in the Treatment of Nonspecific Chronic Neck Pain: A Randomized Clinical Trial. JAMA Netw Open 5(12):e2246538. 10.1001/jamanetworkopen.2022.46538 Huang Y et al (Nov. 2022) Effect of Yijinjing combined with elastic band exercise on muscle mass and function in middle-aged and elderly patients with prediabetes: A randomized controlled trial. Front Med 9:990100. 10.3389/fmed.2022.990100 Yan W (2023) The Traditional Chinese Medicine Daoyin Method, 1st edn. China Traditional Chinese Medicine, Beijing, China. [Online]. Available: www.cptcm.com Arffa RE, Krishna P, Gartner-Schmidt J, Rosen CA (Jul. 2012) Normative Values for the Voice Handicap Index-10. J Voice 26(4):462–465. 10.1016/j.jvoice.2011.04.006 Hoehn MM, Yahr MD (1967) Parkinsonism: onset, progression, and mortality. Neurology , vol. 57, no. 10 Suppl 3, p. S11, 2001 Folstein MF, Folstein SE, McHugh PR (1975) ‘Mini-mental state,’ Journal of Psychiatric Research , vol. 12, no. 3, pp. 189–198, Nov. 10.1016/0022-3956(75)90026-6 Boogers LS, Chen BSJ, Coerts MJ, Rinkel RNPM, Hannema SE (Nov. 2022) Mobile Phone Applications Voice Tools and Voice Pitch Analyzer Validated With LingWAVES to Measure Voice Frequency. J Voice 0892199722003186:S. 10.1016/j.jvoice.2022.10.013 Karlsson F, Hartelius L (2019) How Well Does Diadochokinetic Task Performance Predict Articulatory Imprecision? Differentiating Individuals with Parkinson’s Disease from Control Subjects. Folia Phoniatr Logop 71:5–6. 10.1159/000498851 Rusz J, Tykalova T, Ramig LO, Tripoliti E (2021) Guidelines for Speech Recording and Acoustic Analyses in Dysarthrias of Movement Disorders, Movement Disorders , vol. 36, no. 4, pp. 803–814, Apr. 10.1002/mds.28465 Wuyts FL et al (2000) Jun., The Dysphonia Severity Index: An Objective Measure of Vocal Quality Based on a Multiparameter Approach, J Speech Lang Hear Res , vol. 43, no. 3, pp. 796–809, 10.1044/jslhr.4303.796 Mautner HD (2016) Effects of an Open Jaw Posture on Vowel Perception in the Aging Voice, Journal of Voice , vol. 30, no. 6, p. 772.e23-772.e32, Nov. 10.1016/j.jvoice.2015.11.011 Niu CM, Lee K, Houde JF, Sanger TD (Jan. 2015) Vowel generation for children with cerebral palsy using myocontrol of a speech synthesizer. Front Hum Neurosci 8. 10.3389/fnhum.2014.01077 Hillenbrand J, Getty LA, Clark MJ, Wheeler K (May 1995) Acoustic characteristics of American English vowels. J Acoust Soc Am 97(5):3099–3111. 10.1121/1.411872 Sapir S, Ramig LO, Fox CM (2011) Intensive voice treatment in Parkinson’s disease: Lee Silverman Voice Treatment, Expert Review of Neurotherapeutics , vol. 11, no. 6, pp. 815–830, Jun. 10.1586/ern.11.43 Ikui Y et al (May 2015) An Aerodynamic Study of Phonations in Patients With Parkinson Disease (PD). J Voice 29(3):273–280. 10.1016/j.jvoice.2014.08.012 Additional Declarations No competing interests reported. Supplementary Files supplementary.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3977487","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274271310,"identity":"ee6bcc6f-e907-4057-8e4a-1a3251311b58","order_by":0,"name":"xin sun","email":"","orcid":"","institution":"Ruijin Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"xin","middleName":"","lastName":"sun","suffix":""},{"id":274271311,"identity":"13330946-b669-4c4c-9322-3b4c0a34992b","order_by":1,"name":"Mei Yang","email":"","orcid":"","institution":"The Affiliated Chuzhou Hospital of Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mei","middleName":"","lastName":"Yang","suffix":""},{"id":274271312,"identity":"c2b737e7-1382-4183-bab5-753054984b76","order_by":2,"name":"Jin Yan","email":"","orcid":"","institution":"Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Yan","suffix":""},{"id":274271313,"identity":"e96f234b-bdb9-459d-b289-82f8b9308b8f","order_by":3,"name":"Linbin Wang","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Linbin","middleName":"","lastName":"Wang","suffix":""},{"id":274271314,"identity":"369bf26a-65cc-48a3-98bc-76abd9f4a581","order_by":4,"name":"Yuxin Sun","email":"","orcid":"","institution":"Ruijin Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuxin","middleName":"","lastName":"Sun","suffix":""},{"id":274271315,"identity":"9cd0db80-174e-49dd-9137-4ec00df08d9b","order_by":5,"name":"Yong Wang","email":"","orcid":"","institution":"Ruijin Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Wang","suffix":""},{"id":274271316,"identity":"2fa59531-ec87-40b4-b98c-6525fbeca804","order_by":6,"name":"Shiqing Yan","email":"","orcid":"","institution":"Shanghai Institute of Inheritance and Daoyin Medicine","correspondingAuthor":false,"prefix":"","firstName":"Shiqing","middleName":"","lastName":"Yan","suffix":""},{"id":274271317,"identity":"cd137663-bee4-475f-a810-8f8e79636122","order_by":7,"name":"Dianyou Li","email":"","orcid":"","institution":"Ruijin Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Dianyou","middleName":"","lastName":"Li","suffix":""},{"id":274271318,"identity":"d735c180-0710-40a2-959c-6cf59a29803b","order_by":8,"name":"Chuanxin M. Niu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIie3RMQuCQBTA8SdCLS9nxahPELwQnIK+yoVrQxCEW0FgX6G+RR9BcXCRWpUadKk5WhzztBr1xqD7L++G94M7DkAm+8XUeiB0N0DV0Rcm6AP5QuSbzt7bbWS06wV5Adc+pfds+fBgoCVMeS4aiB1qjoVwQ7rMiQIPLCNhqrlvJGibACEnwMnsmLCOii3EKDhJo4yTtRDRkZMEqosxEiCWhRSiEZdviU/6+BDnW7ORnONxXrjhVIuiG7mryVCLnODZROrqb++UQy+nsmkFn9RMeFUmk8n+qhfv2kjfLjek6AAAAABJRU5ErkJggg==","orcid":"","institution":"Ruijin Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Chuanxin","middleName":"M.","lastName":"Niu","suffix":""}],"badges":[],"createdAt":"2024-02-22 04:04:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3977487/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3977487/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51718993,"identity":"30dd2d54-8efd-4250-97fd-b39992dee9fe","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129696,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the conventional voice therapy and the adapted posture-voice therapy. A) The body configuration in CVT group, the vocalization was performed while sitting in a chair. B) According to the ninth method of Yijinjing, the Wohu Pushi posture imitates a crouching tiger poised to pounce for food[19], which inspired the posture-voice therapy proposed in this study. C) The body configuration in PVT group, the participant assumes a leg-lunging and hand-clawing posture during vocalization.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/f2616fc1ce044eb81531cb84.png"},{"id":51718997,"identity":"d65d6a7e-6d74-48cb-8160-ac939adb76aa","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65246,"visible":true,"origin":"","legend":"\u003cp\u003eThe sequence of the three tasks—Tone-up (TU), Maximum sustained movements (MS), and Tone-down (TD)—introduced in the training for two groups (PVT vs. CVT). The PVT group performs the exercises in the \"Wohu Pushi\" posture, with alternating leg configurations: eight repetitions with the right leg in the back, followed by eight repetitions with the right leg in the front. The CVT group performed each task in a seated position, with 16 repetitions of each task.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/98e5e5b10101dbbcbc7c8dc1.png"},{"id":51718992,"identity":"4daee221-e5eb-4eb9-9fe1-856263ba809c","added_by":"auto","created_at":"2024-02-27 21:35:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":110143,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the trial. A) the flow diagram for recruitment, group allocation, assessment, and analysis. B) procedure of each visit: participants received interventions of voice training. Data were analyzed before and after the intervention.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/585d441dfe522ed7080e9522.png"},{"id":51718996,"identity":"bdddc2bd-dafe-4e1f-9ac0-102b172e6c07","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":20510,"visible":true,"origin":"","legend":"\u003cp\u003eActual scenes of therapeutic training and assessments. A) A participant performing “Wohu Pushi” posture-voice therapy. The participant performed vocal exercises by leaning with both hands on a height-adjustable table, maintaining a \u003cem\u003elunging-and-clawing\u003c/em\u003e posture. B) the acoustic assessment of participants using lingWAVES. Participants vocalized facing a microphone, while an experimentalist recorded the acoustic parameters of voice.\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/86726c9c7f66df874fc0c585.png"},{"id":51718994,"identity":"c09a48c3-d2c5-403d-b71a-a983b0871207","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":30545,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of MPT duration between two subjects. A) There was a representative participant (Subject09) in the PVT group. The MPT before therapy was 12.19 seconds, which increased to 18.05 seconds after the therapy. B) There was a representative participant (Subject107) in the CVT group. The MPT before therapy was 8.06 seconds, which increased to 9.66 seconds. The increase in the two participants was 48% and 19%, respectively.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/df484d3c10a73cd74cbad4cd.png"},{"id":51719002,"identity":"1fdc4e1f-d69a-49e1-90c3-6150d59526cf","added_by":"auto","created_at":"2024-02-27 21:35:15","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":49069,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of MPT duration between PVT and CVT groups. A) Changes in MPT duration before and after training in PVT Group. red lines indicate the MPT duration change for each patient. B) Changes in MPT duration Before and After training in CVT Group. blue lines represent the MPT duration change for each patient. C) Comparative analysis of the mean slope changes in MPT duration. MPT increased more in the PVT group as compared to the CVT group.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/d8c5a129e75147c1af3a5d45.png"},{"id":51719000,"identity":"9a14eb1d-e861-4c7d-b83d-b6c79ae7d060","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":26556,"visible":true,"origin":"","legend":"\u003cp\u003eThe formants one and two for vowels produced by all participants. Changes in vowel production are depicted as vectors pointing from before the training to after the training, either for /ɑ/ in panel A), /i/ in panel B) or /u/ in panel C). The black bold symbols represent the average formant frequencies (Hz) for U.S. English vowels produced by 45 males [29].\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/4aa1becbe4211d96c67a6c98.png"},{"id":51718998,"identity":"cd71d987-1ed4-4b81-8573-d3ba9cf53595","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":49360,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of ΔF1 between PVT and CVT Groups. A) Changes in ΔF1 before and after training in the PVT Group, with each red line segment representing the ΔF1 for a participant. B) Changes in ΔF1 before and after training in the CVT Group, with each blue line segment indicating the ΔF1 for a participant. C) Pooled data of ΔF1, the PVT group showed an increasing trend, while the CVT group showed a decrease after training.\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/124e4a2b74ea2beef8925cd8.png"},{"id":51718990,"identity":"197ca4b4-047d-4127-92cc-52f5479e0981","added_by":"auto","created_at":"2024-02-27 21:35:13","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":25904,"visible":true,"origin":"","legend":"\u003cp\u003eVector similarities for vowel production in two groups. A) the results for the vowel sound /ɑ/ in both groups. Significant differences were identified, indicating that the average group trend in PVT group is much stronger than CVT group. B) The vector similarity for the vowel /i/, a significant difference existed between the two groups. C) No significant difference between groups in terms of vector similarity for the vowel /u/.\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/a7cd8708c2ccadc6050848b2.png"},{"id":51718995,"identity":"e5abfb4e-2efb-46a1-b43d-d4f3de22e5c5","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":30197,"visible":true,"origin":"","legend":"\u003cp\u003eFour acoustic measures between PVT group and CVT group. A) dysphonia severity index rate (DSI), B) the vowel sound /ɑ/, C) Reading articles, and D) diadochokinetic rate (DDK). No significant effects of GROUP or EVALUATION were found on these acoustic measures.\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/4a4d106d92e5ec6b8fc9d0ec.png"},{"id":51718999,"identity":"3b744e8f-ad71-45f0-bf2a-0a8b4ba0bee8","added_by":"auto","created_at":"2024-02-27 21:35:14","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":18408,"visible":true,"origin":"","legend":"\u003cp\u003eLinear regression of ΔMPT and clinical factors. The linear regression exploring the relationship between ΔMPT and months since diagnosis showed a significant correlation (p \u0026lt; 0.05, panel A). The linear relationship was non-significant betweenΔMPT and UPDRSⅢ (B) or VHI-10 (C).\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/03127cced7b87a2cd7babd3a.png"},{"id":51834948,"identity":"18a8aa17-91dd-4700-b6b3-15d3e42e63ff","added_by":"auto","created_at":"2024-02-29 20:23:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":776490,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/560b99b9-67a4-4cf8-aef2-555b2f69052f.pdf"},{"id":51718991,"identity":"3747355d-18da-4553-a754-0fb82a2cba7d","added_by":"auto","created_at":"2024-02-27 21:35:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17319,"visible":true,"origin":"","legend":"","description":"","filename":"supplementary.docx","url":"https://assets-eu.researchsquare.com/files/rs-3977487/v1/4ad37f69759d175968970a9a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short-term effects of \"Yijinjing Wohu Pushi\" posture-voice therapy on speech in Parkinson's disease after STN-DBS","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eHypokinetic dysarthria (HD) is a speech disorder unique to patients with Parkinson\u0026rsquo;s disease (PD)[1]. HD-PD traumatizes the overall quality of life with PD due to impaired communication and social participation[2], which tend to gradually deteriorate to the point of complete refusal to communicate[3]. Although both levodopa drugs and deep brain stimulation (DBS) have been proven to improve motor symptoms in patients with PD, neither has shown significant therapeutic effects on speech-related impairments[4], [5].\u003c/p\u003e\n\u003cp\u003eSuccessful production of speech depends on a coordinated interplay among respiration, phonation, articulation, resonance, prosody, etc.[6]. Therefore, direct training on these activities have been explicitly studied and administered in rehabilitation clinic for HD-PD[7]. For example, phonation was instrumental in LSVT LOUD[8], a widely tested and accepted therapeutic regime[9]. Respiration is emphasized in Respiratory Muscle Strength Training (RMST), where improvement in the patient\u0026apos;s respiratory muscle strength may result in a greater flow of air to stimulate voice production[10]. Prosody is a key component of the SPEAK-OUT training program, thereby improving monopitch in patients with PD[11]. In addition, posture and movement were also considered important in the selection of therapy goals for the elicitation of better voicing[12]. However, most of the existing therapies imposed minimal, if not none, requirements on how postures should be maintained during vocalization.\u003c/p\u003e\n\u003cp\u003eIncorrect posture and body movements could hinder the recovery of vocalization and even the overall axial symptoms [13], [14]. In specific, a posture with improper alignment of the body tends to facilitate the voice production, due to the excessive the energy expenditure and strain on tissues[15], [16]. Another postural abnormality found commonly with PD is with neck flexion[14]. The soft tissue of the throat and the muscles that raise the larynx can alter due to imbalances in the neck and head, which can affect voice control and resonance [16]. Therefore, therapeutic exercise with postural correction may provide addition benefits for voice production in PD. For instance, Yijinjing is a type of traditional Chinese exercise with explicit emphasis on the coordination of posture, which has been proven to alleviate joint pain[17], increase muscle strength, and improve balance[18]. The ninth method of Yijinjing \u0026ndash; \u0026quot;Wohu Pushi (a crouching tiger to pounce for food)\u0026quot; \u0026ndash; describes a posture-voice exercise. The Wohu Pushi method asks the trainee to imitate a crouching tiger by assuming a \u003cem\u003elunging-and-clawing\u003c/em\u003e posture, and it trains the voice production by imitation of a tiger\u0026rsquo;s roaring[19].\u003c/p\u003e\n\u003cp\u003eIn this study, we added posture maintenance to a conventional voice therapy conforming with LSVT LOUD principles. We present a protocol of posture-voice therapy that PD patients with mild to moderate motor impairments could still participate. Using this protocol, we also examined the posture-voice therapy on speech function in PD patients who received deep-brain stimulation in subthalamic nuclei (STN-DBS). The posture-voice therapy was tested in comparison with the conventional voice therapy, both of which incorporated similar voice exercises but they differed in requirements on posture. Objective measures on acoustic and speech performances were acquired and analyzed. Our main hypothesis was that the posture-voice therapy would incur discernable short-term changes after one session of training. If proven, this study would provide support for a series of experiments to identify the longer-term clinical benefits of posture-voice therapy as well as its neurological mechanisms.\u003c/p\u003e"},{"header":"2\tMethods","content":"\u003cp\u003eWe designed a prospective study to compare speech improvement before and after training in patients with conventional voice therapy (CVT) or posture-voice therapy (PVT). The CVT was derived following LSVT LOUD principles with essential adaptations (Fig.1A), which ensured that the repetition, content, and perceived effort of voice training were similar between groups. We modified the conventional therapy inspired from the ninth method “Wohu Pushi” of Yijinjing, a traditional Chinese exercise (Fig. 1B). By requiring a \u003cem\u003elunging-and-clawing\u003c/em\u003e posture during the conventional voice therapy, the participants received posture-voice therapy in the PVT group (Fig. 1C). Details of CVT and PVT are specified below.\u003c/p\u003e\n\u003ch2\u003e2.1 Training protocols\u003c/h2\u003e\n\u003cp\u003eIn both groups, participants were required to accomplish 3 tasks of phonation specified below.\u003c/p\u003e\n\u003cp\u003eTone-up (TU)：The vowel /ɑ/ is pronounced from low pitch to high pitch, with the entire pronunciation process lasting more than 10 seconds and maintaining a slight hold at the highest pitch.\u003c/p\u003e\n\u003cp\u003eMaximum sustained movements (MS): Prolong the vowel /ɑ/ as much as possible while maintaining vowel pronunciation at 70% of your maximum SPL.\u003c/p\u003e\n\u003cp\u003eTone-down (TD): The vowel /ɑ/ is pronounced from high pitch to low pitch, with the entire pronunciation process lasting more than 10 seconds and maintaining a slight hold at the lowest pitch.\u003c/p\u003e\n\u003cp\u003eThe primary differences between groups were with the posture maintenance during phonation tasks.\u003c/p\u003e\n\u003cp\u003eThe CVT group, the participant performed the above phonation tasks while remaining seated in the chair throughout the vocalization training.\u003c/p\u003e\n\u003cp\u003eIn the PVT group, the key requirement was the maintenance of a \u003cem\u003elunging-and-clawing\u003c/em\u003e posture during voice production. The lunging required that the participant started with a stance at shoulder-width, and lunged to keep the forward thigh horizontal. The forward knee should align with the toe. The behind leg should be extended straight. Meanwhile the trunk should stay upright.\u003c/p\u003e\n\u003cp\u003eThe clawing required that the participant started with their hands shoulder-width apart, fingers spread, with the fingertips pressing against the tabletop. The elbows should be straight, shoulders relaxed, and chest raised. During vocalization, the cervical spine should be extended backward and the mouth opened as wide as possible. The experimenter helped the participant adjust the height of the table to the lowest clearance without losing stability.\u003c/p\u003e\n\u003cp\u003eThe sequence of trials in both groups are listed in (Fig. 2). Each participant, either in the PVT or CVT group, accomplished 48 repetitions of vocalization tasks. Verbal feedback and encouragement were given to the participant after each trial of vocalization. Rests were given ad-hoc between trials as required by the participants.\u003c/p\u003e\n\u003ch2\u003e1.1 Study Design\u003c/h2\u003e\n\u003cp\u003eParticipants were recruited from February to June 2023 from the outpatient Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. The inclusion criteria were: (1) More than 6 months after bilateral STN-DBS surgery for PD; (2) No adjustments to medication or DBS stimulation parameters in the past 3 months; (3) VHI-10＞11 [20]; (4) Within Stages Ⅰto Ⅳ on the Hoehn Yahr scale[21]; (5) No significant cognitive impairment (MMSE⩾25)[22]; (6) Age 18 and above; (7) Native Chinese speaker. The exclusion criteria were: (1) Diagnosed previously or currently with diseases that affect swallowing function (such as vocal nodules, gastroesophageal reflux, laryngeal cancer, and other laryngeal diseases); (2) Having difficulty breathing, fever, lung infection or chronic lung disease, or abnormal oral structure; (3) Due to various other reasons, the training tasks required for this study cannot be completed.\u003c/p\u003e\n\u003cp\u003eAllocation of participants into groups was accomplished using a computer program with random number generation (Fig. 3A). All PD participants were on levodopa medication with daily routine of dosage. Each patient underwent a speech assessment, followed by the phonation exercise as required by the allocated group. Immediately after training, another speech assessment was carried out. Each participant practiced 5-10 trials of phonation (either TD/MS/TU) as a familiarization to the protocol. The entire visit took approximately 1.5 hours (Fig. 3B). All participants gave written consent as approved by the Ethics Committee of Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University (No. 224 of 2022). The training was administered by certified inheritors of Yijinjing (The National List of Intangible Cultural Heritage of China, Project No. IX-2) and licensed LSVT-LOUD therapists (ONLOUDCH1121-52, 0822-18, 0822-19, 1122-04).\u003c/p\u003e\n\u003ch2\u003e1.2 Data Acquisition\u003c/h2\u003e\n\u003cp\u003eSpeech recordings were performed in a quiet room with a low ambient noise level using a condenser microphone placed approximately 30 cm from the subject’s mouth (Fig. 4). Speech signals were sampled at 48 kHz with 16-bit resolution. Our acoustic indicators including MPT, DSI, SPL/ɑ/, SPL\"Reading\", DDK rate, and vowel production(/ɑ/,/i/,/u/), collected through the following acoustic tasks[23]–[26].\u003c/p\u003e\n\u003cp\u003eMaximum phonation time (MPT, in seconds) – take a deep breath, and sustain the vowel \"ah\" as long as possible, record the longest phonation out of three measures as MPT;\u003c/p\u003e\n\u003cp\u003eFundamental frequency (F\u003csub\u003e0\u003c/sub\u003e, in Hz) - maintain a comfortable volume and a consistent tone while sustaining the vowel sound /ɑ/ for more than 3 seconds;\u003c/p\u003e\n\u003cp\u003eHighest frequency (F\u003csub\u003e0\u003c/sub\u003e-High, in Hz) - gradually increase the tone of \"ah\" from normal speaking to the highest point and sustain it for 1-2 seconds;\u003c/p\u003e\n\u003cp\u003eLowest intensity (I-Low, in dB) - Start at a normal volume, sound \"ah\", and gradually decrease the volume;\u003c/p\u003e\n\u003cp\u003eDiadochokinetic rate (DDK rate, in syllables per second) - produce the syllables /pa/, /ta/, and /ka/ as quickly as possible for as long as you can;\u003c/p\u003e\n\u003cp\u003eVowel production - pronounce the vowels /ɑ/, /i/, and /u/ as smoothly and comfortably as possible, maintaining the sound for more than 3 seconds;\u003c/p\u003e\n\u003cp\u003eSPL/ɑ/ (in dB) - acoustic record reference fundamental frequency;\u003c/p\u003e\n\u003cp\u003eSPL\"Reading\" (in dB) - read the story of \"The North Wind and the Sun\" at a comfortable pitch and loudness, as if you are having a regular conversation.\u003c/p\u003e\n\u003cp\u003e(Figure. 4 is omitted due to exposure of patient images; the figure is available upon request to the corresponding authors.)\u003c/p\u003e\n\u003cp\u003eFigure. 4. Actual scenes of therapeutic training and assessments. A) A participant performing “Wohu Pushi” posture-voice therapy. The participant performed vocal exercises by leaning with both hands on a height-adjustable table, maintaining a \u003cem\u003elunging-and-clawing\u003c/em\u003e posture. B) the acoustic assessment of participants using lingWAVES. Participants vocalized facing a microphone, while an experimentalist recorded the acoustic parameters of voice.\u003c/p\u003e\n\u003cp\u003eUsing the PRAAT software, select the formant one frequency F1 and the formant two frequency F2 for the vowels /ɑ/, /i/, and /u/ respectively. The software LingWAVES (Software Version 3.2, Wevosys) was used for voice measurements. Analyze the acoustic data of the participants using PRAAT (version 6.3.08) software.\u003c/p\u003e\n\u003ch2\u003e1.3 Outcome measures and statistical analysis\u003c/h2\u003e\n\u003cp\u003eThe primary outcome measure in this study was ΔMPT , defined as the difference in maximum phonation time before and after the training.\u003c/p\u003e\n\u003cp\u003eAnother outcome measure was the formant-distance, defined as the frequency difference\u003c/p\u003e\n\u003cp\u003ebetween the formant one of /ɑ/ and , i.e. [27].\u003c/p\u003e\n\u003cp\u003eThe third outcome measure was the vector-similarity between the participant-pronounced vector and the group-averaged vector, which was calculated based on the one and two formants of each vowel. Since the first two formants of vowel formed a 2-dimensional vector on the frequency plane [28], we were interested in the similarity between the participant-pronounced vector and the group-averaged vector. This outcome measure aimed to quantify whether a participant showed congruent changes compared to his/her group trend. It was calculated as follows:\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted using R (version 4.3.0). Between-group comparisons were conducted either using Welch’s t-test, or by a two-way repeated-measure analysis of variance (RM-ANOVA) with factors of GROUP (PVT vs. CVT) and EVALUATION (before training, after training) formulated as follows:\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Baseline characteristics of the participants\u003c/h2\u003e \u003cp\u003eWe screened 42 candidates who agreed to participate. A total of 20 participants finished the study, with 10 in the PVT group (3 male and 7 females, age 62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.29) and 10 in the CVT group (6 male and 4 females, age 65.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.42). No statistical differences were found between groups in age, sex, months since diagnosis, months since surgery, Hoehn-Yahr (HY) scale, Unified Parkinson\u0026rsquo;s Disease Rating Scale III (UPDRS III), or Voice Handicap Index-10 (VHI-10) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Refer to the supplementary materials for details about the stimulation setting.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePVT group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCVT group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, M/F\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonths since diagnosis*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136.2\u0026thinsp;\u0026plusmn;\u0026thinsp;61.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165.6\u0026thinsp;\u0026plusmn;\u0026thinsp;64.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.311\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonths since surgery*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.2\u0026thinsp;\u0026plusmn;\u0026thinsp;27.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u0026thinsp;\u0026plusmn;\u0026thinsp;21.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHY scale*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUPDRS III score*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.3\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.332\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVHI-10 score*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e#Based on the Fisher's exact test.\u003c/p\u003e \u003cp\u003e* Group means compared using Welch\u0026rsquo;s t-test.\u003c/p\u003e \u003cp\u003eM, male; F, female; HY, Hoehn\u0026ndash;Yahr scale; UPDRS III, Unified Parkinson\u0026rsquo;s Disease Rating Scale III; VHI-10, Voice Handicap Index-10.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Maximum phonation time\u003c/h2\u003e \u003cp\u003e Voice time series of /ɑ/ pronunciation from representative participants in each group are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e. As can be seen, Subject09 in the PVT group performed with an increase in MPT after training, while Subject107 in the CVT group also had an increase in MPT, but the change was smaller.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePooled data suggest that the PVT group exhibited an overall increasing trend in MPT scores post-intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003eA), while the CVT group showed inconsistent MPT changes among participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003eB). A 2\u0026times;2 two-way repeated-measures ANOVA (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003eC) indicated a significant main effect of EVALUATION on MPT (F\u003csub\u003e1,18\u003c/sub\u003e =14.305, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). No significant main effect for GROUP (F\u003csub\u003e1,18\u003c/sub\u003e = 0.064, p\u0026thinsp;=\u0026thinsp;0.803) was found. The interaction between GROUP and EVALUATION was significant (F\u003csub\u003e1,18\u003c/sub\u003e =8.843, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), suggesting that the PVT and CVT groups differed in MPT score changes over time. Post-hoc comparison with the Tukey test showed a significant increase in MPT for the PVT group from \"Before\" to \"After\" (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but the changes were non-significant in the CVT group (p\u0026thinsp;=\u0026thinsp;0.939).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Vowel production\u003c/h2\u003e \u003cp\u003eWe plotted the vector change graph on a two-dimensional plane, with the starting and ending points of the vector being the formant frequency before and after training, respectively(Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e7\u003c/span\u003e)[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePooled data suggest that the PVT group exhibited an overall increasing trend in formant-distance (∆F1) after the therapy (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e8\u003c/span\u003eA), while the majority of participants in CVT group showed a decline (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e8\u003c/span\u003eB). A 2\u0026times;2 two-way repeated-measures ANOVA (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003eC) indicated no significant main effect of GROUP on ∆F1 (F\u003csub\u003e1,18\u003c/sub\u003e = 2.856, p\u0026thinsp;=\u0026thinsp;0.108) or main effect of EVALUATION (F\u003csub\u003e1,18\u003c/sub\u003e = 1.436, p\u0026thinsp;=\u0026thinsp;0.246). However, the interaction between EVALUATION and GROUP was significant (F\u003csub\u003e1,18\u003c/sub\u003e = 12.362, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Post-hoc comparison with the Tukey test showed a significant increase in ∆F1 within the PVT group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) but not in CVT group (p\u0026thinsp;=\u0026thinsp;0.383).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe vector-similarity \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(d\\left({v}_{i}\\right)\\)\u003c/span\u003e\u003c/span\u003e between the individual vectors and group-averaged vectors was analyzed. Welch\u0026rsquo;s t-test showed that for the vowel /ɑ/, the vector-similarity in PVT group was larger compared to that in CVT group (t\u003csub\u003e9.842\u003c/sub\u003e = 3.165, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e9\u003c/span\u003eA); Welch\u0026rsquo;s t-test was chosen because it allowed for comparisons between groups that did not confirm homoscedasticity. For the vowel /i/, the vector-similarity was smaller in PVT compared to CVT (t\u003csub\u003e9.181\u003c/sub\u003e=-2.691, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e9\u003c/span\u003eB). Vowel /u/ showed no significant changes between groups (t\u003csub\u003e18\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.857, p\u0026thinsp;=\u0026thinsp;0.402, Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e9\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.4 DSI, SPL, DDK rate\u003c/h2\u003e \u003cp\u003eFor other acoustic measures, we did not detect any significant main effects of GROUP or EVALUATION (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e10\u003c/span\u003e), and no significant interactions were found.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Correlation betweenΔMPT and other factors\u003c/h2\u003e \u003cp\u003eDue to the significant improvement shown by MPT in the results, we continued to explore whether changes in MPT (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\Delta }\\text{M}\\text{P}\\text{T}\\)\u003c/span\u003e\u003c/span\u003e) could be explained by known clinical profiles of participants. Linear regressions showed a significant correlation between \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\Delta }\\text{M}\\text{P}\\text{T}\\)\u003c/span\u003e\u003c/span\u003e and the months-since-diagnosis, i.e. the longer months since diagnosis, the more significant the improvement in MPT after one training session. The linear relationship is \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\text{y}=0.026\\text{x}+0.372\\)\u003c/span\u003e\u003c/span\u003e (one-tailed p\u0026lt;0.05, R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.311, Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e11\u003c/span\u003e). \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\Delta }\\text{M}\\text{P}\\text{T}\\)\u003c/span\u003e\u003c/span\u003e was not significantly correlated with UPDRS III or VHI-10.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study developed a protocol for conducting voice training for PD patients after STN-DBS. The protocol specified that a \u003cem\u003elunging-and-clawing\u003c/em\u003e posture should be maintained during vocalization. A pilot study was conducted to examine the short-term benefit of posture-voice therapy compared with conventional voice therapy that did not impose posture requirements. Results showed that after one session of training, the posture-voice therapy (PVT) managed to elongate the maximum phonation time and the formant-distance better than the conventional voice therapy (CVT). Our results suggested more prominent improvements if the patients received longer periods of \"Wohu Pushi\" posture-voice therapy. This short-term protocol was not sensitive enough to detect significant changes in acoustic measures including DSI, SPL, and DDK rate. Overall, our results indicated that adding posture requirements to conventional voice therapy for PD patients could facilitate recovery on voice and speech production.\u003c/p\u003e \u003cp\u003eOne reason why posture-voice therapy elongated MPT more than did the conventional voice therapy, is that MPT associates with the respiratory capacity during speech production[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. By assuming the typical \"Wohu Pushi\u0026rdquo;posture, subjects may have learned to inspire to a higher percentage of their vital capacities, due to the stretching of the respiratory muscles (including the intercostal muscles, the sternocleidomastoid muscles and pectoralis major muscles), thereby increasing the amount of available air stream used for phonation.\u003c/p\u003e \u003cp\u003eIt is noteworthy that the formant-distance in PVT group was larger than that in CVT group, even though both groups emphasized on keeping the mouth open during training. Formant-distance is a quantitative measure of the acoustic form of the degree of mouth opening, which is generally proportional to the quality of the pronunciation[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The repeated flexion and extension of the cervical spine during training in the PVT group may stimulate the proprioception of the relevant muscles in the jaw, thereby improving the sensory processing of the jaw.\u003c/p\u003e \u003cp\u003eOur current experimental setup did not allow us to differentiate the contribution between leg lunging and hand supporting. Although this study demonstrates that overall postural vocalization can improve certain acoustic indicators, whether the upper or lower limbs contribute more to vocalization, allowing us to optimize it more in the future, remains to be further investigated.\u003c/p\u003e \u003cp\u003eIn conclusion, this pilot study suggests that by requiring adequate posture maintenance in a conventional voice therapy, we have developed a clinically viable protocol that PD patients with STN-DBS could accomplish even with mild to moderate motor impairments. The posture-voice therapy is likely more effective in improving MPT and formant-distance compared to the conventional voice therapy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eCVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003econventional voice therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eDBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003edeep brain stimulation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eDDK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003ediadochokinetic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eDSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003edysphonia severity index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003ehypokinetic dysarthria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eHY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003eHoehn-Yahr scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eLSVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003eLee Silverman Voice Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eMMSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003emini-mental state examination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eMPT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003emaximum phonation time\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003emaximum sustained movements\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003ePD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003eParkinson\u0026rsquo;s disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003ePVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003eposture-voice therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eRMST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003eRespiratory Muscle Strength Training\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eRM-ANOVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003erepeated-measures analysis of variance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eSPL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003esound pressure level\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eSTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003esubthalamic nucleus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eTD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003etone-down\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eTU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003etone-up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eUPDRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003eUnified Parkinson\u0026rsquo;s Disease Rating Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.15270935960591%\"\u003e\n \u003cp\u003eVHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"76.84729064039409%\"\u003e\n \u003cp\u003eVoice Handicap Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization, C.M.N. and D.Y.L.; formal analysis, X.S. and Y.X.S; funding acquisition, D.Y.L. and C.M.N.; investigation, X.S. and J.Y.; methodology, X.S., M.Y., J.Y., and C.M.N.; project administration, D.Y.L. and C.M.N.; resources, D.Y.L.; supervision, S.Q.Y. and Y.W.; writing—original draft, X.S.; writing—review and editing, L.B.W, D.Y.L., and C.M.N. All authors have read and agreed to the published version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research was funded by \"Shanghai General Hospital Integrated Traditional Chinese and Western Medicine Special Project\" grant number: ZHYY-ZXYJHZX-202103. \"Shanghai STC International Science and Technology Cooperation Project\" grant number:22490711000.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethics Committee of Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University (no. 224 of 2022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u003c/strong\u003e Informed consent was obtained from all subjects involved in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The data presented in this study are available on request from the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors thank Ms. Lu Xu for her assistance with patient recruitment and baseline assessment. We also thank Mr. Qiang Xu from RJH-FFTAI Joint Laboratory for development of essential software to facilitate the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePinto S, Ozsancak C, Tripoliti E, Thobois S, Auzou P (2004) Treatments for dysarthria in Parkinson\u0026rsquo;s disease. Lancet Neurol 3(9):547\u0026ndash;556\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller N, Noble E, Jones D, Burn D (May 2006) Life with communication changes in Parkinson\u0026rsquo;s disease. Age Ageing 35(3):235\u0026ndash;239. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ageing/afj053\u003c/span\u003e\u003cspan address=\"10.1093/ageing/afj053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchalling E, Johansson K, Hartelius L (2017) Speech and Communication Changes Reported by People with Parkinson\u0026rsquo;s Disease. Folia Phoniatr Logop 69(3):131\u0026ndash;141. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000479927\u003c/span\u003e\u003cspan address=\"10.1159/000479927\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHariz M, Blomstedt P (2022) Deep brain stimulation for Parkinson\u0026rsquo;s disease, \u003cem\u003eJ Intern Med\u003c/em\u003e, vol. 292, no. 5, pp. 764\u0026ndash;778, Nov. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/joim.13541\u003c/span\u003e\u003cspan address=\"10.1111/joim.13541\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTykalov\u0026aacute; T et al (2015) Aug., Effect of dopaminergic medication on speech dysfluency in Parkinson\u0026rsquo;s disease: a longitudinal study, \u003cem\u003eJ Neural Transm\u003c/em\u003e, vol. 122, no. 8, pp. 1135\u0026ndash;1142, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00702-015-1363-y\u003c/span\u003e\u003cspan address=\"10.1007/s00702-015-1363-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYorkston KM (Oct. 1996) Treatment Efficacy: Dysarthria. J Speech Lang Hear Res 39(5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1044/jshr.3905.s46\u003c/span\u003e\u003cspan address=\"10.1044/jshr.3905.s46\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerd CP et al (2012) Aug., Comparison of speech and language therapy techniques for speech problems in Parkinson\u0026rsquo;s disease, \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD002814.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD002814.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamig L, Halpern A, Spielman J, Fox C, Freeman K (2018) Speech treatment in Parkinson\u0026rsquo;s disease: Randomized controlled trial (RCT): SPEECH TREATMENT IN PARKINSON\u0026rsquo;S DISEASE: RCT, \u003cem\u003eMov Disord.\u003c/em\u003e, vol. 33, no. 11, pp. 1777\u0026ndash;1791, Nov. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/mds.27460\u003c/span\u003e\u003cspan address=\"10.1002/mds.27460\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahler LA, Ramig LO, Fox C (2015) Evidence-based treatment of voice and speech disorders in Parkinson disease:, \u003cem\u003eCurrent Opinion in Otolaryngology \u0026amp; Head and Neck Surgery\u003c/em\u003e, vol. 23, no. 3, pp. 209\u0026ndash;215, Jun. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MOO.0000000000000151\u003c/span\u003e\u003cspan address=\"10.1097/MOO.0000000000000151\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhuang J, Jia J (Jun. 2022) Effects of Respiratory Muscle Strength Training on Respiratory-Related Impairments of Parkinson\u0026rsquo;s Disease. Front Aging Neurosci 14:929923. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fnagi.2022.929923\u003c/span\u003e\u003cspan address=\"10.3389/fnagi.2022.929923\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoutsen FR, Park E, Dvorak JD (2023) An Efficacy Study of Voice Quality Using Cepstral Analyses of Phonation in Parkinson\u0026rsquo;s Disease before and after SPEAK-OUT!\u0026reg;. Folia Phoniatr Logop 75(1):35\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000525884\u003c/span\u003e\u003cspan address=\"10.1159/000525884\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBehrman A (Sep. 2005) Common Practices of Voice Therapists in the Evaluation of Patients. J Voice 19(3):454\u0026ndash;469. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvoice.2004.08.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jvoice.2004.08.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngsuwarangsee T, Morrison M (Sep. 2002) Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders. J Voice 16(3):333\u0026ndash;343. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0892-1997(02)00105-4\u003c/span\u003e\u003cspan address=\"10.1016/S0892-1997(02)00105-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshii F, Moriya Y, Ohnuki T, Ryo M, Takahashi W (Dec. 2016) Postural deformities in Parkinson\u0026rsquo;s disease \u0026ndash;Mutual relationships among neck flexion, fore-bent, knee-bent and lateral-bent angles and correlations with clinical predictors. J Clin Mov Disord 3(1):1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40734-016-0029-8\u003c/span\u003e\u003cspan address=\"10.1186/s40734-016-0029-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArboleda BMW, Frederick AL (2008) Considerations for maintenance of postural alignment for voice production. J Voice 22(1):90\u0026ndash;99\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardoso R, Lumini-Oliveira J, Meneses RF (2019) Associations between Posture, Voice, and Dysphonia: A Systematic Review, \u003cem\u003eJournal of Voice\u003c/em\u003e, vol. 33, no. 1, p. 124.e1-124.e12, Jan. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvoice.2017.08.030\u003c/span\u003e\u003cspan address=\"10.1016/j.jvoice.2017.08.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng Z et al (Dec. 2022) Effectiveness of Tuina Therapy Combined With Yijinjing Exercise in the Treatment of Nonspecific Chronic Neck Pain: A Randomized Clinical Trial. JAMA Netw Open 5(12):e2246538. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2022.46538\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2022.46538\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang Y et al (Nov. 2022) Effect of Yijinjing combined with elastic band exercise on muscle mass and function in middle-aged and elderly patients with prediabetes: A randomized controlled trial. Front Med 9:990100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fmed.2022.990100\u003c/span\u003e\u003cspan address=\"10.3389/fmed.2022.990100\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan W (2023) The Traditional Chinese Medicine Daoyin Method, 1st edn. China Traditional Chinese Medicine, Beijing, China. [Online]. Available: www.cptcm.com\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArffa RE, Krishna P, Gartner-Schmidt J, Rosen CA (Jul. 2012) Normative Values for the Voice Handicap Index-10. J Voice 26(4):462\u0026ndash;465. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvoice.2011.04.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jvoice.2011.04.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoehn MM, Yahr MD (1967) Parkinsonism: onset, progression, and mortality. \u003cem\u003eNeurology\u003c/em\u003e, vol. 57, no. 10 Suppl 3, p. S11, 2001\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFolstein MF, Folstein SE, McHugh PR (1975) \u0026lsquo;Mini-mental state,\u0026rsquo; \u003cem\u003eJournal of Psychiatric Research\u003c/em\u003e, vol. 12, no. 3, pp. 189\u0026ndash;198, Nov. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/0022-3956(75)90026-6\u003c/span\u003e\u003cspan address=\"10.1016/0022-3956(75)90026-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoogers LS, Chen BSJ, Coerts MJ, Rinkel RNPM, Hannema SE (Nov. 2022) Mobile Phone Applications Voice Tools and Voice Pitch Analyzer Validated With LingWAVES to Measure Voice Frequency. J Voice 0892199722003186:S. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvoice.2022.10.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jvoice.2022.10.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarlsson F, Hartelius L (2019) How Well Does Diadochokinetic Task Performance Predict Articulatory Imprecision? Differentiating Individuals with Parkinson\u0026rsquo;s Disease from Control Subjects. Folia Phoniatr Logop 71:5\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000498851\u003c/span\u003e\u003cspan address=\"10.1159/000498851\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRusz J, Tykalova T, Ramig LO, Tripoliti E (2021) Guidelines for Speech Recording and Acoustic Analyses in Dysarthrias of Movement Disorders, \u003cem\u003eMovement Disorders\u003c/em\u003e, vol. 36, no. 4, pp. 803\u0026ndash;814, Apr. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/mds.28465\u003c/span\u003e\u003cspan address=\"10.1002/mds.28465\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWuyts FL et al (2000) Jun., The Dysphonia Severity Index: An Objective Measure of Vocal Quality Based on a Multiparameter Approach, \u003cem\u003eJ Speech Lang Hear Res\u003c/em\u003e, vol. 43, no. 3, pp. 796\u0026ndash;809, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1044/jslhr.4303.796\u003c/span\u003e\u003cspan address=\"10.1044/jslhr.4303.796\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMautner HD (2016) Effects of an Open Jaw Posture on Vowel Perception in the Aging Voice, \u003cem\u003eJournal of Voice\u003c/em\u003e, vol. 30, no. 6, p. 772.e23-772.e32, Nov. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvoice.2015.11.011\u003c/span\u003e\u003cspan address=\"10.1016/j.jvoice.2015.11.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiu CM, Lee K, Houde JF, Sanger TD (Jan. 2015) Vowel generation for children with cerebral palsy using myocontrol of a speech synthesizer. Front Hum Neurosci 8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fnhum.2014.01077\u003c/span\u003e\u003cspan address=\"10.3389/fnhum.2014.01077\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHillenbrand J, Getty LA, Clark MJ, Wheeler K (May 1995) Acoustic characteristics of American English vowels. J Acoust Soc Am 97(5):3099\u0026ndash;3111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1121/1.411872\u003c/span\u003e\u003cspan address=\"10.1121/1.411872\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSapir S, Ramig LO, Fox CM (2011) Intensive voice treatment in Parkinson\u0026rsquo;s disease: Lee Silverman Voice Treatment, \u003cem\u003eExpert Review of Neurotherapeutics\u003c/em\u003e, vol. 11, no. 6, pp. 815\u0026ndash;830, Jun. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1586/ern.11.43\u003c/span\u003e\u003cspan address=\"10.1586/ern.11.43\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIkui Y et al (May 2015) An Aerodynamic Study of Phonations in Patients With Parkinson Disease (PD). J Voice 29(3):273\u0026ndash;280. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvoice.2014.08.012\u003c/span\u003e\u003cspan address=\"10.1016/j.jvoice.2014.08.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Parkinson’s disease, rehabilitation, vocalization, posture, deep brain stimulation","lastPublishedDoi":"10.21203/rs.3.rs-3977487/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3977487/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHypokinetic dysarthria in Parkinson's Disease (HD-PD) deteriorates patients' quality of life by impeding communication and social engagement. Existing treatments like levodopa drugs and deep brain stimulation (DBS) can improve motor symptoms but fall short in addressing speech-related impairments; effective speech therapies tend not to mandate the posture, which potentially hinders vocal performance. Here we first proposed a therapeutic protocol that specified a lunging-and-clawing posture (Wohu Pushi method from Yijinjing) during vocalization training. The protocol aimed to ensure that PD patients could accomplish the training even with moderate motor impairments. A total of 20 HD-PD patients with implanted stimulators in subthalamic nuclei (STN-DBS) participated in one session of training, either following our posture-voice therapy (PVT) or the conventional voice therapy (CVT). Results indicated that the maximum phonation time was significantly elongated in PVT(3.85±2.81s) but not in CVT(0.46±2.24s), and the formant-distance was significantly increased in PVT(95.80±112.71Hz) compare to CVT(-47.10±84.28Hz). Our results indicated that by demanding appropriate amount of postural maintenance during vocalization, it might facilitate the recovery of speech-related functions. This study warranted larger-scale clinical trials to understand the impact, limitation, and optimization of posture-voice therapy for HD-PD.\u003c/p\u003e","manuscriptTitle":"Short-term effects of \"Yijinjing Wohu Pushi\" posture-voice therapy on speech in Parkinson's disease after STN-DBS","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-27 21:35:08","doi":"10.21203/rs.3.rs-3977487/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c77f507c-e47b-4104-bf03-4ed6fe7dd549","owner":[],"postedDate":"February 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-29T20:14:57+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-27 21:35:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3977487","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3977487","identity":"rs-3977487","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}