J Neural Transm

DOI 10.1007/s00702-016-1662-y

NEUROLOGY AND PRECLINICAL NEUROLOGICAL STUDIES - ORIGINAL ARTICLE

Comparative analysis of speech impairment and upper limb

motor dysfunction in Parkinsons disease
Jan Rusz1,2 Tereza Tykalova1 Radim Krupicka3 Katerina Zarubova4

Michal Novotny1 Robert Jech2 Zoltan Szabo3 Evzen Ruzicka2

Received: 20 September 2016 / Accepted: 1 December 2016

 Springer-Verlag Wien 2016

Abstract It is currently unknown whether speech and limb
motor effectors in Parkinsons disease (PD) are controlled
by similar underlying brain processes. Based on comput-
erized objective analysis, the aim of this study was to
evaluate potential correlation between speech and
mechanical tests of upper limb motor function. Speech and
upper limb motor tests were performed in 22 PD patients
and 22 healthy controls. Quantitative acoustic analyses of
eight key speech dimensions of hypokinetic dysarthria,
including quality of voice, sequential motion rates, con-
sonant articulation, vowel articulation, average loudness,
loudness variability, pitch variability, and number of pau-
ses, were performed. Upper limb movements were assessed
using the motor part of the Unified Parkinsons Disease
Rating Scale, contactless three-dimensional motion capture
system, blinded expert evaluation, and the Purdue Peg-
board Test. Significant relationships were observed
Electronic supplementary material The online version of this
article (doi:10.1007/s00702-016-1662-y) contains supplementary
material, which is available to authorized users.
& Evzen Ruzicka
eruzi@lf1.cuni.cz
1
Department of Circuit Theory, Faculty of Electrical
Engineering, Czech Technical University in Prague, Prague,
Czech Republic
2
Department of Neurology and Centre of Clinical
Neuroscience, First Faculty of Medicine, Charles University,
Prague, Czech Republic
3
Department of Biomedical Informatics, Faculty of
Biomedical Engineering, Czech Technical University in
Prague, Kladno, Czech Republic
4 termed hypokinetic dysarthria, which develops in up to
Department of Neurology, 2nd Faculty of Medicine and
Motol University Hospital, Charles University, Prague,
Czech Republic
between the quality of voice assessed by jitter and ampli-
tude decrement of finger tapping (r = 0.61, p = 0.003),
consonant articulation evaluated using voice onset time and
expert rating of finger tapping (r = 0.60, p = 0.003), and
number of pauses and Purdue Pegboard Test score
(r = 0.60, p = 0.004). The current study supports the
hypothesis that speech impairment in PD shares, at least
partially, similar pathophysiological processes with limb
motor dysfunction. Vocal fold vibration irregularities
appeared to be influenced by mechanisms similar to
amplitude decrement during repetitive limb movements.
Consonant articulation deficits were associated with
decreased manual dexterity and movement speed, likely
reflecting fine motor control involvement in PD.
Keywords Parkinsons disease
Bradykinesia

Hypokinetic dysarthria
Speech and voice disorders
Limb
function
Motion capture
Introduction
Bradykinesia results from the failure of basal ganglia out-
put to reinforce cortical mechanisms that prepare and
execute movement commands (Berardelli et al. 2001).
Bradykinesia is considered a key feature of Parkinsons
disease (PD) and is used as a general term encompassing
not only motor slowness, but also poverty of spontaneous
movements (akinesia) and reduced amplitude of move-
ments (hypokinesia) (Hallett and Khoshbin 1980; Marsden
1989). It is thus debated to what extent bradykinesia is
related to speech abnormalities in PD (Zarzur et al. 2007),
90% of patients in the course of the illness (Logemann
et al. 1978; Ho et al. 1999).

123

However, there is a dearth of knowledge whether speech
and limb motor effectors are controlled by similar under-
lying brain processes. To date, prevailing evidence sug-
gests that hypokinetic dysarthria is related particularly to
axial motor symptoms (Midi et al. 2008; Skodda et al.
2011a, 2012; Defazio et al. 2016), while only a few studies
have documented an association between speech disorder
and limb bradykinesia in PD (Goberman 2005; Rusz et al.
2016). So far, in parallel with a detailed speech assessment,
limb bradykinesia has only been evaluated by the motor
part of the Unified Parkinsons Disease Rating Scale
(UPDRS III). Accurate visual evaluation of simple tasks
such as finger tapping is delicate, and thus, low inter-rater
reliability has been reported (Eichards et al. 1994; Goetz
and Stebbins 2004; Martinez-Martin and Forjaz 2006).
Nevertheless, based upon several tests of manual dexterity
and speed, recent evidence demonstrated that contactless
three-dimensional motion capture of finger tapping allowed
an independent and accurate analysis of individual com-
ponents of bradykinesia with the amplitude decrement and
maximum opening velocity as the most powerful discrim-
inators between PD patients and healthy controls (Ruzicka
et al. 2016). In addition, of the six instrumental tests
investigated, only the Purdue Pegboard Test attained sig-
nificance in differentiating between PD patients and con-
trols (Ruzicka et al. 2016).
Considering dysarthria assessment, acoustic analyses
provide objective, sensitive, and quantifiable information
for the precise assessment of various deviant speech
dimensions (Rusz et al. 2011). With respect to the previous
literature (Robertson and Hammerstadt 1996; Baker et al.
1998; Blumin et al. 2004; Sapir 2014), we hypothesized
that bradykinesia in PD should particularly influence
amplitude of respiratory and thyroarytenoid muscles,
amplitude of vocal cord movements, as well as movements
of lips and tongue. Decreased amplitude of respiratory and
thyroarytenoid muscles is assumed to be at least partially
responsible for hypophonia and monoloudness (Baker et al.
1998; Sapir 2014), which can be acoustically captured by
reduced mean and standard deviation of the intensity
contour (Rusz et al. 2011). Subsequently, reduced ampli-
tude of vocal cord movements may lead to glottal incom-
petence, which may clinically manifest as both irregular
vocal fold vibrations leading to decreased quality of voice
as well as low variety of vibration frequencies resulting in
monopitch speech (Blumin et al. 2004; Sapir 2014). Minor
irregularities in the frequency of vocal fold vibrations can
be acoustically captured via increased jitter of sustained
phonation, whereas overall reduced intonation variability
by lowered standard deviation of the overall pitch contour
of utterance (Rusz et al. 2011). Finally, hypokinesia of the
lips and tongue is likely to cause imprecise consonant and
vowel production as well as a slower rate of articulatory
123
J. Rusz et al.
motions (Robertson and Hammerstadt 1996; Sapir 2014).
Deficit in consonant articulation is acoustically expressed
by increased voice onset time (Novotny et al. 2014), while
articulatory undershoot of vowels is manifested by shift in
formant frequencies that can be assessed using vowel
articulation index (Roy et al. 2009; Rusz et al. 2013a).
Slower motion of articulators is typically reflected by
decreased diadochokinetic rate (Novotny et al. 2014).
Furthermore, since imprecise articulation induces slurring
of intra-word pauses, it can also be captured by decreased
number of pauses (Rusz et al. 2011).
Since comparative computerized objective analysis
between speech and mechanical tests of upper limb motor
function has not been performed to date, the aim of this
study was thus to evaluate potential correlation between
bradykinetic patterns of upper limb movement assessed by
UPDRS III, blinded expert evaluation from video, con-
tactless three-dimensional motion capture system, the
Purdue Pegboard Test, and several key aspects of hypoki-
netic dysarthria based upon acoustic speech analyses in PD
patients.
Patients and methods
Subjects
A total of 22 Czech patients (10 men, 12 women) with
mild-to-moderate PD, mean age 64.4 [standard deviation
(SD) 9.6, range 4882] years, mean Hoehn and Yahr stage
2.0 (SD 0.5, range 12.5), mean disease duration 9.3 (SD
5.5, range 124) years, and mean daily levodopa equivalent
dose (LED) 884 (SD 474, range 2802080) mg participated
in the study. These patients had also participated in a for-
mer study focused on the discriminative properties of
several tests for evaluation of bradykinesia in PD (Ruzicka
et al. 2016); however, results related to possible relation-
ships between speech and upper limb motor assessment
were not previously reported. In addition, the 22 gender-
matched volunteers, mean age 64.5 (SD 9.8, range 5081),
with no history of neuropsychiatric, neurological or com-
munication disorders and without any impairment of upper
limb function, served as healthy controls. Patients with the
tremor dominant form of PD or with marked motor fluc-
tuations or dyskinesias were not included. None of the
patients underwent speech therapy before investigation.
Each patient was examined by both speech and motor
assessment in their best on-medication state during a single
session of approximately 1 h duration.
The study was conducted in compliance with Helsinki
Declaration and was approved by the Ethics Committee of
the General University Hospital in Prague, Czech Repub-
lic. Each participant provided written, informed consent.
Comparative analysis of speech impairment and upper limb motor dysfunction in Parkinsons
Speech assessment
Audio recordings were performed in a quiet room with a
low ambient noise level using a head-mounted condenser
microphone (Beyerdynamic Opus 55, Heilbronn, Ger-
many) placed approximately 5 cm from the subjects
mouth. The speech data were sampled at 48 kHz with
16-bit resolution. Each subject was recorded during one
session with a speech specialist (JR). All participants were
instructed to perform three vocal tasks of (a) sustained
phonation of the vowel/a/per one breath as long and steady
as possible, (b) fast/pa/-/ta/-/ka/syllable repetition at least
seven times per one breath, and (c) reading a short para-
graph of standardized text composed of 80 words. Each
participant repeated all tasks twice per session.
Quantitative acoustic vocal assessment was performed
to investigate eight motor speech dimensions, including
jitter (Boersma and Weenink 2001; Rusz et al. 2011),
diadochokinetic rate (Novotny et al. 2014), voice onset
time (Novotny et al. 2014), vowel articulation index (Roy
et al. 2009; Rusz et al. 2013a), mean intensity (Rusz et al.
2011), intensity variability (Rusz et al. 2011), pitch vari-
ability (Boersma and Weenink 2001; Rusz et al. 2011), and
number of pauses (Rusz et al. 2011). Acoustic features
investigated in the current study were chosen to allow
objective and gender-independent assessment (Rusz et al.
2011). Each acoustic feature represents a unique speech
subsystem (Pearson: r \ 0.5 between all speech measure-
ments). To increase the overall accuracy of measurements,
the final values were calculated by averaging the data for
each participant obtained in two vocal task runs; although
the testretest reliability across the first and second vocal
task repetitions through all participants was high (Pearson:
r = 0.750.96, p \ 0.001). The definition of investigated
acoustic speech measures is summarized in Table 1, while
detailed description can be found in Supplementary
Material Online.
Motor assessment
The UPDRS III was assessed by a movement disorder
specialist (ER or KZ). Subsequently, the axial motor sub-
score and limb bradykinesia subscore were computed.
Estimation of speech disorder severity was based upon
UPDRS III item 18.
The finger tapping subtest of the UPDRS III, item 23,
was recorded using a contactless three-dimensional motion
capture system (Optitrack-V120; NaturalPoint, Inc., Cor-
vallis, OR USA). The system measures the mutual distance
of light, passive-reflexive markers placed on the distal
phalanx of the thumb and forefinger (Krupicka et al. 2014).
Subjects were instructed to tap the index finger against the
thumb as quickly as possible and with the largest amplitude
possible. The test was performed with each hand twice for
15-s duration. Computational analysis of the recordings
was performed using amplitude decrement and maximum
opening velocity. Averages of the movement descriptors
obtained in two recordings were used for further
calculations.
Simultaneous video recordings were obtained by a
common high-resolution camera mounted on the same
rack. The videos were independently rated by two move-
ment disorder specialists (KZ and ER) according to
UPDRS III item 23 criteria. The recordings from both the
PD and control groups were presented in a random order,
showing only the subjects hand and shading the rest of the
picture window. Satisfactory agreement between the two
raters was proven by computation of Cohens kappa
coefficient (j = 0.59, moderate agreement). Averages of
both expert scores for finger tapping rated from video were
used in further calculations.
In the Purdue Pegboard Test (Lafayette Instrument
Company), the subject was instructed to pick up pins one at
a time using only his dominant hand and to insert them into
holes on the board as fast as possible for 30-s duration. The
mean number of pins placed in the board in two consecu-
tive trials served as the Purdue Pegboard Test score for the
dominant hand. The same was done for the non-dominant
hand.
As speech disorder does not imply bilateral involve-
ment, the final values for amplitude decrement, maximum
opening velocity, expert rating of finger tapping, and Pur-
due Pegboard Test were averaged from the performance of
both dominant and non-dominant hands. The definition of
investigated limb measures is summarized in Table 1,
while detailed description can be found in Supplementary
Material Online.
Statistics
The KolmogorovSmirnov test revealed that all investi-
gated parameters were normally distributed. An indepen-
dent-sample t test was used to assess group differences.
Pearson correlations were applied to test for significant
relationships. Since there was a relationship between Pur-
due Pegboard Test and LED (r = -0.56, p = 0.007), the
Pearsons partial correlation analysis controlled for LED
was performed to test for significant relationships between
Purdue Pegboard Test and speech variables; no other cor-
relations between LED and any speech or limb measures
were found (Pearson; r = -0.35 to 0.34, p = 0.090.99).
As the seven limb measures investigated represented
dependent variables, the Bonferroni adjustment for multi-
ple comparisons was performed for correlations between
speech and motor measures according to the eight speech
measures investigated, where the minimal level of
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 J. Rusz et al.

Table 1 Overview of applied measurements

Variable Task Description

Speech
Jitter Sustained phonation of Quality of voice measurement based on frequency perturbation, representing extent of
the vowel/a/ variation of voice range. Jitter is defined as the variability of the fundamental frequency of
speech from one cycle to the next
Diadochokinetic rate Fast/pa/-/ta/-/ Sequential motion rates measurement defined as the number of syllable vocalizations per
ka/syllable repetition second
Voice onset time Fast/pa/-/ta/-/ Consonant articulation measurement defined as the length of the stop consonant from the
ka/syllable repetition initial burst to vowel onset
Vowel articulation Reading passage Vowel articulation measurement based on centralization of the first (F1) and second (F2)
index formant frequencies defined as VAI = (F1a ? F2i)/(F1i ? F1u ? F2a ? F2u). F1 and F2
for each vowel were averaged by the extraction of ten defined corner vowels
Mean intensity Reading passage Average squared amplitude within a predefined time-energy segment
Intensity variability Reading passage Standard deviation of intensity contour after removing a period of silence exceeding 60 ms
and relative calibration to the reference of 0 dB
Pitch variability Reading passage Standard deviation of fundamental frequency contour converted to a semitone scale
Number of pauses Reading passage Number of pauses relative to total speech time after removing periods of silence lasting less
than 60 ms
Limb
UPDRS III total Motor examination Overall motor severity score based on motor part of the unified Parkinsons disease rating
score scale (UPDRS III)
UPDRS III axial Motor examination Axial motor subscore based on UPDRS III items 18, 19, 27, 28, 29, and 30
subscore
UPDRS III Motor examination Bradykinesia motor subscore based on UPDRS III items 23, 24, and 25
bradykinesia
subscore
Amplitude Finger tapping Decrease of amplitude in time defined as ratio between the minimum value of the vector
decrement containing all filtered maximal finger distances between taps and the maximum value of the
vector containing the first five filtered maximal finger distances between taps
Maximum opening Finger tapping Average of maximum opening velocities of fingers in all tapping cycles
velocity
Expert rating of Finger tapping Expert scores for finger tapping rated from video according to UPDRSIII item 23 criteria
finger tapping
Purdue Pegboard Purdue Pegboard The neuropsychological test of manual dexterity and bimanual coordination
Test

significance was set to p \ 0.0063. We did not perform
adjustment for multiple comparisons for secondary analysis
(i.e., difference between PD and control groups) due to its
informative character.
Results
According to the UPDRS III speech item 18, 9 PD
patients (41%) demonstrated normal speech (score of 0),
10 PD patients (45%) mildly affected speech (score of
1), and 3 PD patients (14%) moderately affected speech
(score of 2).
Table 2 further provides numerical data as well as
comparison between PD and controls for both speech
and limb motor function. Considering speech analysis,
compared to controls, the PD group showed primarily
monopitch (pitch variability: p \ 0.001), imprecise
vowel articulation (vowel articulation index: p = 0.02),
imprecise consonant articulation (voice onset time:
p = 0.04), and decreased quality of voice (jitter:
p = 0.04). From the upper limb motor analysis, signifi-
cant differences between PD and controls were found for
all measures, including the Purdue Pegboard Test
(p \ 0.001), amplitude decrement (p \ 0.001), maxi-
mum opening velocity (p = 0.001), and expert rating of
finger tapping (p = 0.02).
Table 3 shows the results of primary correlation analysis
between speech and limb motor data for the PD group. We
observed significant relationships between the jitter and
amplitude decrement (r = 0.61, p = 0.003), consonant
articulation, and expert rating of finger tapping (r = 0.60,
p = 0.003), as well as number of pauses and Purdue Peg-
board Test score (r = 0.60, p = 0.004) (Fig. 1).

123
Comparative analysis of speech impairment and upper limb motor dysfunction in Parkinsons

Table 2 Results of speech

Variable Group Statistics (t test)
measures and limb motor
examinations PD Controls PD vs. controls
Mean (SD) Mean (SD) p Effect sizea

Speech
Jitter (%) 1.07 (0.88) 0.64 (0.75) 0.04 0.64
Diadochokinetic rate (syll/s) 6.36 (0.89) 6.86 (0.94) 0.09 -0.53
Voice onset time (ms) 24.7 (6.4) 21.5 (3.8) 0.04 0.63
Vowel articulation index (-) 0.90 (0.05) 0.94 (0.06) 0.02 -0.76
Mean intensity (dB) 65.3 (3.3) 65.2 (3.1) 0.94 0.02
Intensity variability (dB) 7.04 (0.84) 6.83 (0.74) 0.38 0.27
Pitch variability (st) 2.02 (0.64) 2.73 (0.72) \0.001 -1.15
Number of pauses (pauses/s) 4.36 (0.79) 4.70 (0.77) 0.14 -0.45
Limb
UPDRS III total score (-) 15.9 (7.6)
UPDRS III axial subscore (-) 3.36 (2.32)
UPDRS III bradykinesia subscore (-) 5.95 (2.55)
Amplitude decrement (-) 0.22 (0.10) 0.10 (0.11) \0.001 1.37
Maximum opening velocity (cm/s) 82.6 (19.9) 108.4 (27.6) 0.001 -1.08
Expert rating of finger tapping (-) 1.32 (0.52) 0.95 (0.52) 0.02 0.77
Purdue Pegboard Test (pins/30 s) 10.7 (2.2) 13.3 (2.4) \0.001 -1.19
a
Cohens d: effect size 0.8 considered large, 0.5 medium, and 0.2 small

Table 3 Correlations between speech measures and limb motor examinations

Pearson: r (p) UPDRS III UPDRS III UPDRS III Amplitude Maximum Expert rating of finger Purdue
total score axial bradykinesia decrement opening tapping from video Pegboard Test
subscore subscore velocity

Jitter 0.26 (0.24) 0.39 (0.08) 0.28 (0.21) 0.61 (0.003) -0.31 (0.16) 0.41 (0.06) -0.20 (0.38)
Diadochokinetic -0.33 (0.14) -0.26 (0.23) -0.37 (0.09) 0.40 (0.06) -0.05 (0.80) -0.04 (0.87) 0.20 (0.38)
rate
Voice onset time 0.32 (0.14) 0.46 (0.03) 0.34 (0.12) 0.04 (0.88) -0.30 (0.18) 0.60 (0.003) -0.56 (0.008)
Vowel -0.12 (0.61) 0.18 (0.43) -0.24 (0.28) -0.20 (0.38) -0.36 (0.10) -0.06 (0.80) -0.04 (0.85)
articulation
index
Mean intensity -0.04 (0.85) -0.15 (0.51) -0.14 (0.54) 0.13 (0.57) 0.30 (0.17) -0.11 (0.61) -0.08 (0.72)
Intensity -0.20 (0.38) -0.31 (0.34) -0.23 (0.29) 0.38 (0.08) 0.10 (0.65) 0.24 (0.28) -0.04 (0.85)
variability
Pitch variability -0.03 (0.91) 0.11 (0.62) -0.03 (0.89) -0.07 (0.74) -0.01 (0.97) 0.08 (0.74) -0.13 (0.57)
Number of -0.10 (0.66) -0.30 (0.18) -0.05 (0.84) -0.15 (0.51) 0.10 (0.65) -0.51 (0.02) 0.60 (0.004)
pauses
Bold numbers indicate significant relationship between speech and limb assessment
UPDRS unified Parkinsons disease rating scale

Discussion voice, consonant articulation and pause production, and

The current study supports the hypothesis that speech
impairment in PD shares, at least partially, similar patho-
physiological processes with limb motor dysfunction. We
revealed several direct correlations between quality of
tests of manual dexterity and speed in PD. Notably, these
correlations cannot be considered a simple effect of overall
disease severity, as no significant correlation between
speech measures and UPDRS motor score was observed. In
addition, no relation was found between vocal function and

123
 J. Rusz et al.

0.5 air flow and muscle contraction is likely not fast enough to
r = 0.61, p = 0.003
correct or cause vocal cycle-to-cycle frequency disturbs.
0.4
decrement ()

Since the micro-fluctuation of vocal folds is not specific for

Amplitude

0.3 basal ganglia dysfunction and can be observed in other

progressive neurodegenerative disorders as well (Acker-
0.2
mann and Ziegler 1994), another variable contributing to
0.1 increased jitter such as vocal fold bowing cannot be
excluded (Blumin et al. 2004).
0 We further observed a significant relationship between
0 1 2 3 4
Jitter (%) voice onset time and expert ratings of finger tapping.
Worse performance in consonant articulation, particularly
2.5 during rapid syllable repetition, corresponds to slowing of
r = 0.60, p = 0.003
of finger tapping ()

lip and tongue movements. PD patients thus require a

2 longer time to pronounce individual consonants. Prolonged
Expert rating

voice onset time, therefore, not only represents another

1.5 feature of hypokinetic dysarthria correlating with limb
bradykinesia, but, in itself, it reflects the slowing of artic-
1 ulatory movements and dysfunction of fine motor control,
likely sharing similar pathophysiological mechanisms with
0.5 limb bradykinesia. In addition, Purdue Pegboard scores
10 20 30 40
correlated with the speech measure of number of pauses.
Voice onset time (ms)
While a worse performance on the Purdue Pegboard Test
16 may be considered a reflection of decreased manual dex-
r = 0.60, p = 0.004
terity, a lower number of pauses may be caused by artic-
Purdue Pegboard
Test (pins/30 s)

14
12
10
8 that shares similar mechanisms with limb bradykinesia in
6 Surprisingly, no correlations were found between the
2 3 4 5
Number of pauses (pauses/s)
Fig. 1 Significant results of correlation analyses between acoustic
speech measures and upper limb motor examinations
axial motor symptoms, supporting the assumption that
analysed speech subsystems are rather associated with limb
bradykinesia than axial motor involvement.
The progressive decrement of amplitude during repeti-
tive movements reflects the sequence effect, which is
considered one of the distinguishing features of bradyki-
nesia in PD (Iansek et al. 2006; Ling et al. 2012). Similarly,
based on a large sample of PD patients, voice disorder has
been reported as the most prevalent feature of hypokinetic
dysarthria (Logemann et al. 1978). In accordance, we
revealed a relationship between decreased quality of voice
by means of increased jitter and amplitude decrement of
finger tapping in PD. However, this finding needs to be
interpreted with caution. To produce voiced speech sounds,
the vocal folds perform hundreds of vibration clicks during
the same amount of time required to perform several finger
taps. Moreover, vocal fold vibration is elicited passively by
ulatory slurring of intra-word pauses that require precise
articulation, especially occlusive consonants (Skodda and
Schlegel 2008). Consequently, a reduced number of pauses
may represent another feature of hypokinetic dysarthria
PD.
6
acoustic measures of jitter and voice onset time and the
parameters of bradykinesia obtained by finger tapping
analysis, likely due to the fact that each of the measures of
amplitude decrement, maximum opening velocity, or
expert rating of finger taping represents different aspects of
bradykinesia. While the progressive decrement of ampli-
tude during repetitive movements reflects the sequence
effect (Iansek et al. 2006; Ling et al. 2012), opening
velocity of finger tapping is particularly influenced by
decreased speed of movement (Yokoe et al. 2009). Expert
rating of finger tapping can be then considered as an
evaluation of overall manual dexterity and movement
speed (Goetz and Stebbins 2004; Ruzicka et al. 2016).
Since our PD patients were investigated under
dopaminergic medication, comparison between parameters
of speech and general motor performance in PD patients
may be compromised by the differing dopaminergic sen-
sitivity of brain systems for speech and limb function
(Pinto et al. 2011; Maillet et al. 2012). While dopaminergic
therapy provides beneficial effects on general motor per-
formance in PD, its effect on dysarthria remains uncertain.
In the early stage of disease, dopaminergic medication

123
Comparative analysis of speech impairment and upper limb motor dysfunction in Parkinsons
seems to have beneficial effect on speech performance for
certain patients (Skodda et al. 2010; Rusz et al. 2016),
whereas in the more advanced stages, dysarthria appears to
become unresponsive to pharmacotherapy (Ho et al. 2008).
Furthermore, the various aspects of dysarthria may respond
differentially to dopaminergic treatment, as voice quality,
vowel articulation, loudness variability, and pitch vari-
ability have been found to improve (Rusz et al. 2013b),
while timing aspects related to velocity, pauses, and
rhythm seem to be rather independent from dopaminergic
stimulation (Skodda et al. 2011b, 2011c). Interestingly, in
comparison to controls, limb function in the present PD
group appeared to be affected to a greater extent than
speech, as limb motor assessment showed large effect
sizes, while speech measures showed rather low-to-med-
ium effect sizes. Indeed, our PD group manifested rather
mild speech impairment as indicated by the UPDRS III
speech item. In particular, we were not able to confirm the
hypothesis that bradykinesia is responsible for decreased
loudness and monoloudness, likely reflecting the very low
severity of loudness abnormalities in our PD group.
It is noteworthy to point out that correlations revealed
between specific measures of speech and upper limb motor
performance do not necessarily imply a causal relationship
or a common pathophysiological mechanism. In particular,
speech deviations related to rhythm appear to share similar
pathomechanisms with gait abnormalities in PD (Moreau
et al. 2007; Cantiniaux et al. 2010; Park et al. 2014). In
addition, certain relationship between vocal performance
and cognitive function cannot be excluded as impairment
of speech rhythmicity was shown to predict a more rapid
cognitive decline in PD (Rektorova et al. 2016).
There are some limitations to this study. Our findings
are based on a relatively small sample of PD patients that is
heterogeneous concerning age, disease duration, Hoehn
and Yahr stage, and dosage of medication. Our PD patients
were examined, whilst on dopaminergic medication,
whereas off-medication assessment might be more appro-
priate to reveal pathological mechanisms of both speech
and limb motor impairment. Therefore, our pilot results
should be confirmed in a larger population sample,
including a broader range of dysarthria severity in both off-
and on-medication states.
In conclusion, the present results underscore several
common features of limb and speech dysfunction in PD.
Vocal fold vibration irregularities appeared to be influ-
enced by mechanisms that are similar to amplitude decre-
ment during repetitive limb movements. Consonant
articulation deficits were associated with decreased manual
dexterity and movement speed, likely reflecting the
involvement of fine motor control in PD. The results of the
present pilot study warrant further evaluation in a larger
population to verify that speech and limb function are
affected by similar pathophysiological mechanisms in PD,
and to elucidate the mechanisms by which the brain con-
trols different effectors involved in motor control.
Acknowledgements This study was supported by the Ministry of
Health of the Czech Republic, Grant Nos. 15-28038A and
16-28119A. All rights reserved.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
References
Ackermann H, Ziegler W (1994) Acoustic analysis of vocal instability
in cerebellar dysfunction. Ann Otol Rhinol Layngol 103:98104
Baker KK, Ramig LO, Luschei ES, Smith ME (1998) Thyroarytenoid
muscle activity associated with hypophonia in Parkinsons
disease and aging. Neurology 51:15921598
Berardelli A, Rothwell JC, Thompson PD, Hallett M (2001)
Pathophysiology of bradykinesia in Parkinsons disease. Brain
124:21312146
Blumin JH, Pcolinsky D, Atkins JP (2004) Laryngeal findings in
advanced Parkinsons disease. Ann Otol Rhinol Laryngol
113:253258
Boersma P, Weenink D (2001) PRAAT, a system for doing phonetics
by computer. Glot Int 5:341345
Cantiniaux S, Vaugoyeau M, Robert D, Horrelou-Pitek C, Mancini J,
Witjas T, Azulay JP (2010) Comparative analysis of gait and
speech in Parkinsons disease: hypokinetic or dysrhythmic
disorders? J Neurol Neurosurg Psychiatry 81:177184
Defazio G, Guerrieri M, Liuzzi D, Gigante AF, di Nicola V (2016)
Assessment of voice and speech symptoms in early Parkinsons
disease by the Robertson dysarthria profile. Neurol Sci
37:443449
Eichards M, Marder K, Cote L, Mayeux R (1994) Interrater reliability
of the Unified Parkinsons Disease Rating Scale motor exam-
ination. Mov Disord 9:8991
Goberman AM (2005) Correlation between acoustic speech charac-
teristics and non-speech motor performance in Parkinson
disease. Med Sci Monit 11:109116
Goetz CG, Stebbins GT (2004) Assuring interrater reliability for the
UPDRS motor section: utility of the UPDRS teaching tape. Mov
Disord 19:14531456
Hallett M, Khoshbin S (1980) A physiological mechanism of
bradykinesia. Brain 103:301314
Ho AK, Iansek R, Marigliani C, Bradshaw J, Gates S (1999) Speech
impairment in large sample of patients with Parkinsons disease.
Behav Neurol 11:131137
Ho AK, Bradshaw JL, Iansek R (2008) For better or worse: the effect
of levodopa on speech in Parkinsons disease. Mov Disord
23:575580
Iansek R, Huxham F, McGinley J (2006) The sequence effect and gait
festination in Parkinson disease: contributors to freezing of gait?
Mov Disord 21:14191424
Krupicka R, Szabo Z, Viteckova S, Ruzicka E (2014) Motion capture
system for finger movement measurement in parkinson disease.
Radioeng 23:659664
Ling H, Massey LA, Lees AJ, Brown P, Day BL (2012) Hypokinesia
without decrement distinguishes progressive supranuclear palsy
from Parkinsons disease. Brain 135:11411153
123

Logemann JA, Fisher HB, Boshes B, Blonsky ER (1978) Frequency
and cooccurrence of vocal tract dysfunction in the speech of a
large sample of Parkinson patients. J Speech Hear Disord
43:4757
Maillet A, Krainik A, Debu B, Tropres I, Lagrange C, Thobois S,
Pollak P, Pinto S (2012) Levodopa effects on hand and speech
movements in patients with Parkinsons disease: a FMRI study.
PLoS One 7:e46541
Marsden CD (1989) Slowness of movement in Parkinsons disease.
Mov Disord Suppl 1:S26S37
Martinez-Martin P, Forjaz MJ (2006) Metric attributes of the unified
Parkinsons disease rating scale 3.0 battery: Part I, feasibility,
scaling assumptions, reliability, and precisions. Mov Disord
21:11821188
Midi I, Dogan M, Koseoglu M, Can G, Sehitoglu MA, Gunal DI
(2008) Voice abnormalities and their relation with motor
dysfunction in Parkinsons disease. Acta Neurol Scand
117:2634
Moreau C, Ozsancak C, Blatt JL, Derambure P, Destee A, Defebvre L
(2007) Oral festination in Parkinsons disease: biomechanical
analysis and correlation with festination and freezing of gait.
Mov Disord 22:15031506
Novotny M, Rusz J, Cmejla R, Ruzicka E (2014) Automatic
evaluation of articulatory disorders in Parkinsons disease.
IEEE/ACM Trans Audio Speech Lang Process 22:13661378
Park HK, Yoo JY, Kwon M, Lee JH, Lee SJ, Kim SR, Kim MJ, Lee
MC, Lee SM, Chung SJ (2014) Gait freezing and speech
disturbance in Parkinsons disease. Neurol Sci 35:3571336
Pinto S, Mancini L, Jahanshahi M, Thornston JS, Tripoliti E, Yousry
TA, Limousin P (2011) Functional magnetic resonance imaging
exploration of combined hand and speech movements in
Parkinsons disease. Mov Disord 26:22122219
Rektorova I, Mekyska J, Janousova E, Kostalova M, Eliasova I,
Mrackova M, Berankova D, Necasova T, Smekal Z, Marecek R
(2016) Speech prosody impairment predicts cognitive decline in
Parkinsons disease. Parkinsonism Relat Disord 29:9095
Robertson LT, Hammerstadt JP (1996) Jaw movement dysfunction
related to Parkinsons disease and partially modified by
levodopa. J Neurol Neurosurg Psyhiatry 60:4150
Roy N, Nissen SL, Dromey C, Sapir S (2009) Articulatory changes in
muscle tension dysphonia: evidence for vowel space expansion
following manual circumlaryngeal therapy. J Commun Disord
42:124135
Rusz J, Cmejla R, Ruzickova H, Ruzicka E (2011) Quantitative
acoustic assessment of speech and voice disorders in early
untreated Parkinsons disease. J Acoust Soc Am 129:350367
123
J. Rusz et al.
Rusz J, Cmejla R, Tykalova T, Ruzickova H, Klempir J, Majerova V,
Picmausova J, Roth J, Ruzicka E (2013a) Imprecise vowel
articulation as a potential early marker of Parkinsons disease:
Effect of speaking task. J Acoust Soc Am 134:21712181
Rusz J, Cmejla R, Ruzickova H, Klempir J, Majerova V, Picmausova
J, Roth J, Ruzicka E (2013b) Evaluation of speech impairment in
early stages of Parkinsons disease: a prospective study with the
role of pharmacotherapy. J Neural Transm 120:319329
Rusz J, Tykalova T, Klempir J, Cmejla R, Ruzicka E (2016) Effects
of dopaminergic replacement therapy on motor speech disorders
in Parkinsons disease: longitudinal follow-up study on previ-
ously untreated patients. J Neural Transm 123:379387
Ruzicka E, Krupicka R, Zarubova K, Rusz J, Jech R, Szabo Z (2016)
Tests of manual dexterity and speed in Parkinsons disease: Not
all measure the same. Parkinsonism Relat Disord 28:118123
Sapir S (2014) Multiple factors are involved in the dysarthria
associated with Parkinsons disease: a review with implications
for clinical practice and research. J Speech Lang Hear Res
57:13301343
Skodda S, Schlegel U (2008) Speech rate and rhythm in Parkinsons
disease. Mov Disord 23:985992
Skodda S, Wenke V, Schlegel U (2010) Short- and long-term
dopaminergic effect on dysarthria in early Parkinsons disease.
J Neural Transm 117:21972205
Skodda S, Visser W, Schlegel U (2011a) Gender related patterns of
dysprosody in Parkinsons disease and correlation between
speech variables and motor symptoms. J Voice 25:7682
Skodda S, Gronheit W, Schlegel U (2011b) Intonation and speech rate
in Parkinsons disease: general and dynamic aspects and
responsiveness to levodopa admission. J Voice 25:e199e205
Skodda S, Flasskamp A, Schlegel U (2011c) Instability of syllable
repetition in Parkinsons diseaseinfluence of levodopa and
deep brain stimulation. Mov Disord 26:728730
Skodda S, Gronheit W, Schlegel U (2012) Impairment of vowel
articulation as a possible marker of disease progression in
Parkinsons disease. PLoS One 7:e32132
Yokoe M, Okuno R, Hamasaki T, Kurachi Y, Akazawa K, Sakoda S
(2009) Opening velocity, a novel parameter, for finger tapping
test in patients with Parkinsons disease. Parkinsonism Relat
Disord 15:440444
Zarzur AR, Duprat G, Shinzato G, Eckley CA (2007) Laryngel
electromyography in adults with Parkinsons disease and voice
complaints. Laryngoscope 117:831834