Selected publications

• Enhanced pitch centering in individuals with laryngeal dystonia

  Frontiers in Human Neuroscience · 2026-02-26

  articleOpen access

  Introduction Laryngeal dystonia (LD) is a neurological voice disorder marked by strained voice quality, pitch instability, and sudden voice breaks, yet the mechanisms underlying impaired vocal control are poorly understood. One key process, known as pitch centering, reflects the central nervous system’s ability to correct early pitch deviations during an utterance by converging toward an intended target. While pitch centering provides a sensitive window into the neural control of spontaneous speech, it remains unexamined in patients with LD and is presumed to contribute to disordered regulation of voice production. Methods Here, we examined pitch centering in 24 individuals with LD [adductor LD ( n = 20), abductor LD ( n = 3), or both ( n = 1)] compared to 29 healthy controls. The primary outcome measures were: (1) Pitch centering and (2) Pitch movement . Pitch centering was defined as the difference in the absolute values of initial (0–50 ms) and mid-trial (150–200 ms) pitch. Positive values (centering > 0) indicated a shift toward the median pitch defined as centering trials. Pitch movement was defined as the difference between mid-trial and initial pitch. In a subset of trials, we observed negative values of centering reflecting movement away from intended pitch targets, which we defined as anticentering trials. An additional subset of trials was defined as overshoot trials , instances where the normalized pitch movement crosses the median pitch at mid-trial. Results Initial pitch deviation ( p < 0.0001) and pitch movement magnitude ( p < 0.0001) were significantly greater in individuals with LD compared to controls across all trials. Importantly, individuals with LD exhibited more pronounced centering responses compared to controls, with greater centering magnitude observed by a significant group-by-tercile interaction ( p = 0.028). Individuals with LD and controls showed similar distributions of centering and anticentering trial types. However, LD patients exhibited significantly greater centering magnitude compared to controls across each trial type. Discussion These findings offer valuable insights into speech motor and predictive control processes in LD, with potential implications for clinical assessment and treatment strategies aimed at improving patient quality of life.

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• The San Diego Consensus for Laryngopharyngeal Symptoms and Laryngopharyngeal Reflux Disease

  The American Journal of Gastroenterology · 2025-04-08 · 22 citations

  articleOpen access

  INTRODUCTION: The term laryngopharyngeal reflux (LPR) is frequently applied to aerodigestive symptoms despite lack of objective reflux evidence. The aim of this initiative was to develop a modern care paradigm for LPR supported by otolaryngology and gastroenterology disciplines. METHODS: A 28-member international interdisciplinary working group developed practical statements within the following domains: definition/terminology, initial diagnostic evaluation, reflux monitoring, therapeutic trials, behavioral factors and therapy, and risk stratification. Literature reviews guided statement development and were presented at virtual/in-person meetings. Each statement underwent 2 or more rounds of voting per the RAND Appropriateness Method; statements reaching appropriateness with ≥80% agreement are included as recommendations. RESULTS: The term laryngopharyngeal symptoms (LPS) applies to aerodigestive symptoms with potential to be induced by reflux and include cough, voice change, throat clearing, excess throat phlegm, and throat pain. Laryngopharyngeal reflux disease (LPRD) refers to patients with LPS and objective evidence of reflux. Importantly, the presence of LPS does not equate to LPRD. Laryngoscopy has value in assessing for nonreflux laryngopharyngeal processes, but laryngoscopic findings alone cannot diagnose LPRD. LPS patients should be categorized as with or without concurrent esophageal reflux symptoms. While lifestyle modification and empiric trials of acid suppression ± alginates are appropriate when esophageal reflux symptoms coexist, upper endoscopy and ambulatory reflux monitoring are required for LPRD diagnosis when symptoms persist, when LPS is isolated, or when management needs to be escalated to include invasive antireflux management. The two recommended ambulatory reflux monitoring modalities, 24-hour pH-impedance and 96-hour wireless pH monitoring, are not mutually exclusive with distinct roles for the evaluation of LPS. Laryngeal hyperresponsiveness and hypervigilance commonly contribute to both LPS and LPRD presentations and are responsive to laryngeal recalibration therapy and neuromodulators. DISCUSSION: The San Diego Consensus represents the formal modern-day interdisciplinary care paradigm to evaluate and manage LPS and LPRD.

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• Is thalamic deep brain stimulation the right target to improve laryngeal dystonia symptoms?

  Dystonia · 2025-09-30 · 1 citations

  articleOpen access

  Introduction Laryngeal dystonia (LD), formerly known as spasmodic dysphonia, is one of the common forms of focal dystonia characterized by involuntary spasms in the laryngeal muscles that selectively impair speech production. The current standard of care for patients with LD is symptom management with botulinum injections (BoNT) into the affected laryngeal muscles1. However, BoNT is ineffective in nearly 40% of LD patients2, and responders have benefits for only about 30% of each injection cycle3. Thus, developing effective, long-lasting therapeutic interventions for these patients is critical, as highlighted during the latest NIH workshops on research priorities in dystonia1, 4. The published article by Honey and colleagues5 presents the first clinical trial assessing deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus (Vim-DBS) as a treatment option for LD. The authors present six patients with LD and voice tremor (VT), who were recruited for the phase I prospective randomized double-blind cross-over trial to investigate the safety and efficacy of unilateral (left) Vim-DBS. Patients were randomized into two groups: one group received 3 months of DBS stimulation (DBS-ON) followed by 3 months of no stimulation (DBS-OFF), while the other group underwent the reverse sequence. The DBS outcomes relevant to voice symptoms were assessed using Voice-Related Quality of Life (V-RQOL), Voice Handicap Index (VHI), and the Unified Spasmodic Dysphonia Rating Scale (USDRS) questionnaires. Given the lack of effective and long-lasting treatment options for these patients, this is an important area of study that requires rigorous methodological and statistical approaches. Our multidisciplinary team has critically assessed the reported findings and identified that the conclusions of this study should be interpreted with greater caution, taking into account the likely weight of this study's outcomes on shaping future research and setting standards for the clinical care of these patients. Major Findings and Their Interpretation In this section, we highlight major findings and limitations of this study. First, the study was designed as a double-blinded clinical trial, which is a standard for robust evaluation of treatment effects. However, the authors report that all patients became aware of the used blinded sequence during the study, rendering the study's blinding unsuccessful. Moreover, it appears that patients were retrospectively asked to find out which group they were randomized to, as they "correctly guessed which blinded group they were in". As this procedure is not defined in the study's clinical protocol, the motivation for the additional retrospective unblinding is unclear. Second, the cross-over design did not include a wash-out period between DBS-ON and OFF conditions, likely contaminating the effects of each condition. These design failures are critical because they effectively reclassified the study as an open-label trial. Therefore, the authors' presentation of this trial, followed by the discussion of its outcomes as if patients were part of a double-blind crossover study design, is misleading. As a recommendation, adherence to the clinical trial protocol is imperative, as invasive procedures, such as DBS, are associated with a stronger placebo effect (over 50%) compared to non-invasive treatment options 6, 7. Relevant to the symptom assessment as a primary outcome of Vim-DBS surgery, the symptom quantification measurements used in this study were not specific to capturing LD symptoms. The V-RQOL and VHI are patient-reporting measures that assess the impact of voice on an individual's well-being and quality of life. It is a well-known clinical observation that the quality of life and LD symptom severity do not necessarily correlate, as patients with mild symptoms may experience greater challenges with their quality of life than those with more severe symptoms. Furthermore, these measurements do not differentiate between disorder-specific aspects of voice symptoms, such as LD-characteristic voice breaks or VT-characteristic rhythmic oscillations. Similarly, the overall severity component of the USDRS is a compound score of multiple LD-specific (e.g., roughness, breathiness, strain) and VT measurements, without offering differential diagnostics. Because of the lack of specificity, these tools may inaccurately assess LD and VT symptom severity, and, therefore, more specialized assessments of LD-characteristic voice breaks, harshness/strain, breathiness, and tremor have been recommended for the quantification of LD and VT symptoms1, 8, 9. In terms of study outcomes, the authors state that "every patient reported an improvement in quality of life (p = 0.07) and had an improvement in quality of their voice (p = 0.06)". This statement contradicts the actual outcome of this clinical trial, given that one out of six patients did not experience any symptom improvement, thus pointing to an over-generalization of findings. Moreover, all clinical trials ought to strictly adhere to their pre-defined study protocol, including criteria for patient inclusion, statistical methods, and set thresholds for outcome reporting that are published in clinicaltrials.gov prior to study initiation. The reported findings include a patient outside the study's eligible ages and differ in the planned statistics, which were initially set to perform an analysis of variance (ANOVA), followed by Bonferroni-corrected pairwise comparisons. Importantly, the reported findings did not reach statistical significance, indicating that there was no statistically significant improvement of LD voice symptoms following Vim-DBS. These results are similar to previous reports of the therapeutic efficacy of Vim-DBS in patients with LD and VT, which have also failed to show any statistically significant effects10. Therefore, the authors' emphasis that the patients had improvement of their symptoms is not substantiated and should be viewed with great caution. While it is possible that non-significant outcomes were due to the study being underpowered, a discrepancy in responsiveness between LD and VT symptoms may have also contributed to the observed effect. To that end, although all patients were reported to have VT, and some essential tremor (ET), this study did not address the effects of Vim-DBS on the patients' VT symptoms. As such, it remains unclear to what degree the outcomes of this study, albeit statistically non-significant, were driven by the presence of VT symptoms and their response to DBS. Notably, the same group published the therapeutic effects of Vim-DBS in VT patients, showing that bilateral and unilateral Vim-DBS significantly reduced voice symptoms compared to baseline11. These results have since been replicated by other research groups12-15. Moreover, Vim-DBS has been shown to be highly effective in ameliorating other forms of tremor and has become the standard of care for drug-refractory ET since receiving FDA approval in 199716, 17. Thus, in light of the absence of classification of differences between LD and VT symptoms, the results of this study suggest that the reported changes in voice symptoms might have been more due to a reduction of VT than LD symptoms. Unlike tremor, DBS of the globus pallidus pars interna (GPi-DBS) and the subthalamic nucleus (STN-DBS) are most effective in reducing dystonic symptoms, especially in patients with drug-refractory cervical, segmental, and generalized dystonias18. Clinical reports investigating the efficacy of GPi-DBS on LD symptoms without VT have shown some therapeutic efficacy with minimal adverse events19, 20. Specifically, Finger et al. performed a detailed auditory-perceptual evaluation of voice and speech in patients with dystonia following bilateral GPi-DBS, demonstrating significant improvements in voice quality parameters, including overall grade, roughness, and strain at 12 months post-surgery21. Their findings emphasize the delayed yet substantial therapeutic impact of GPi-DBS on voice symptoms, further reinforcing GPi as a suitable target for treating dystonic voice disorders. Similar long-term improvements in voice and speech functions following GPi-DBS were also observed in patients with segmental dystonia22 and patients with Meige syndrome23. A recent comparative investigation between GPi-and Vim-DBS in patients with LD and co-occurring VT demonstrated that GPi-DBS was superior in reducing LD-characteristic voice breaks, continuous voicing, and overall speech intelligibility. In contrast, Vim-DBS was most effective in reducing VT intensity24. Collectively, these studies underscore that GPi-DBS is the scientifically justified neurosurgical target for dystonic voice disorders, compared to Vim. Finally, interpreting the Vim-DBS outcome as a result of modulation of the cerebellar circuitry and relating the latter to the primary pathophysiology of LD and the neurophysiology of speech, in general, is not supported by either the findings of this study or the investigation of the cerebello-thalamic circuitry in these patients. It is notable that a subsequent study by the Honey group25 used diffusion MRI tractography in the same six LD and VT patients to examine a stimulation "sweet spot" of benefit and define individual biomarkers of their Vim-DBS response. To do so, authors arbitrarily categorized individual DBS contacts as "effective" or "ineffective" in improving LD symptoms without reporting statistical or numerical thresholds as part of this classification. The results showed no statistically significant "sweet spot", while the segmentation analysis found that "effective contacts" targeted thalamic areas linked to the sensorimotor region, and "ineffective contacts" targeted areas connected to the prefrontal region. These findings did not correlate with LD symptom improvement. Nevertheless, the study concluded that stimulation of thalamic sensorimotor areas is associated with improvement in LD symptoms and claimed to have identified a novel biomarker for DBS targeting. Although an important research question, these results should be interpreted with caution as they neither identify the primary pathophysiological factors of LD nor define the neural correlates of the Vim-DBS response. Discussion and Recommendations for Future Voice and Speech DBS Research In this commentary, we argue that the negative results of this phase I Vim-DBS clinical trial in LD patients do not support the next phase II investigations of Vim-DBS in this disorder. Given the impact of brain surgery on one hand and the readiness of the vast majority of LD patients to enlist for new treatments on the other hand26, the findings of this study should not be overinterpreted when designing new research studies or making clinical neurosurgical decisions for the treatment of LD. Future clinical trials in LD and other dystonias and movement disorders, in general, should adhere to the guidelines of Good Clinical Practice to ensure the proper design, conduct, analysis, reporting, and interpretation of the data in clinical trials. These are especially important when working with clinical populations that are desperate for treatment. Specifically, clinical trials must strictly adhere to the predetermined clinical trial design, including criteria for patient inclusion and exclusion, and the a priori set hypotheses, methodological analyses, and statistical thresholds. Furthermore, rigorous power analyses must be performed prior to study initiation to ensure an adequate sample size, thereby enhancing the study's ability to detect a true effect and minimize statistical errors. This is imperative in voice and speech studies to control for symptom variability. Voice and speech symptoms can be complex; therefore, clinicians and researchers should clearly define the type and form of speech impairment to be studied. In situations of co-occurring disorders, such as VT with LD, a clear distinction of symptoms and measurement tools must be identified. For a more robust understanding of the clinical symptoms, clinical trials should incorporate both clinician-objective (e.g., acoustic data) and patient-subjective (e.g., questionnaires) outcomes. Lastly, in adherence to general policies for protected health information, open access to voice and speech material and the precise description of DBS electrode contact locations and stimulation parameters should be reported for all patients and trials for replicability purposes.

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• Comparing the Effects of Sensory Tricks on Voice Symptoms in Patients With Laryngeal Dystonia and Essential Vocal Tremor

  Journal of Speech Language and Hearing Research · 2025-02-27 · 7 citations

  articleOpen accessSenior author

  PURPOSE: This pilot study systematically compared voice symptomatology across varied sensory trick conditions in those with laryngeal dystonia (LD), those with essential vocal tremor (EVT), and vocally normal controls (NCs). Sensory tricks are considered signature characteristics of dystonia and were hypothesized to reduce voice symptoms in those with LD compared to EVT and NC groups. METHOD: Five participants from each group (LD, EVT, and NC) completed speech recordings under control and sensory trick conditions (delayed auditory feedback [DAF], vibrotactile stimulation [VTS], and nasoendoscopic recordings with and without topical anesthesia). Comparisons between groups and conditions were made using (a) a paired-comparison paradigm (control vs. sensory condition) listener ratings of voice quality, (b) participant-perceived vocal effort ratings, and (c) average smoothed cepstral peak prominence (CPPS). RESULTS: Participants with EVT displayed significantly worse listener ratings under most sensory trick conditions, whereas participants with LD were rated significantly worse for DAF and VTS conditions only. However, participant vocal effort ratings were similar across all sensory trick conditions. Average CPPS values generally supported listener ratings across conditions and speakers except during DAF, wherein CPPS values increased (i.e., measurably improved voice quality), whereas listener ratings indicated worsened voice quality for both voice disorder groups. CONCLUSIONS: Outcomes of this study did not support the hypothesized influences of sensory trick conditions on LD voice symptoms, with both LD and EVT groups experiencing worsened symptoms under VTS and DAF conditions. These adverse effects on voice symptoms warrant further research to further evaluate neural pathways and associated sensorimotor response patterns that distinguish individuals with LD and EVT. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.28462292.

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• Patient Perception of Vocal Tremor Severity and its Relationship to Acoustic Voice Outcomes: An Exploratory Study

  Tremor and Other Hyperkinetic Movements · 2025-01-01

  articleOpen access

  Background: Vocal tremor profoundly impacts communication, social participation, and quality of life. Although expert auditory-perceptual ratings of vocal tremor severity align with acoustic voice outcomes (e.g., extent of frequency (fo) and intensity modulation), patient perception of their voice remains unexamined despite its clinical importance. This study aimed to characterize the relationship between patient-reported vocal tremor severity and acoustic voice outcomes at baseline and after botulinum toxin injections. Method: Patients diagnosed with vocal tremor affecting multiple structures (ETvt) or tremor only observed in the larynx (LDvt) were recruited. Participants completed the voice section of the Quality of Life in Essential Tremor questionnaire to assess patient perception and performed sustained /ɑ/ at a comfortable pitch and volume, from which acoustic voice outcomes (rate and extent of fundamental frequency [fo] and amplitude [dB] modulation) were derived. A subset of participants received botulinum toxin injections and were reassessed within the therapeutic window (within 12 weeks). Results: Thirty participants (29 females; mean age = 72 years, SD = 11.40) were analyzed. Participants who rated their vocal tremor as “severe” demonstrated higher rate fo (β = 1.20, 95% CI: –0.10, 2.60 Hz) and rate dB (β = 2.30, 95% CI: 0.50, 4.10 Hz) compared to participants who rated their tremor as “moderate”. Participants who rated their tremor as “marked” demonstrated higher rate fo (β = 1.50, 95% CI: 0.30, 2.60 Hz) compared to “moderate” ratings. Improvements in patient perception of vocal tremor and acoustic outcomes were highly heterogenous among seven participants who received botulinum toxin. Discussion: Participants reporting more severe vocal tremor demonstrated more aberrant acoustic voice outcomes. After botulinum toxin injection, substantial heterogeneity was observed in acoustic voice measures which varied based on patient perception of change. These preliminary, exploratory findings provide a foundation for future investigations to define meaningful change in this population.

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• Reliability and Diagnostic Accuracy of Semi-Automated and Automated Acoustic Quantification of Vocal Tremor Characteristics

  Journal of Speech Language and Hearing Research · 2025-05-05 · 2 citations

  articleOpen accessSenior author

  PURPOSE: This study compared three methods of acoustic algorithm-supported extraction and analysis of vocal tremor properties (i.e., rate, extent, and regularity of intensity level and fundamental frequency modulation): (a) visual perception and manual data extraction, (b) semi-automated data extraction, and (c) fully automated data extraction. METHOD: Forty-five midvowel sustained [a:] and [i:] audio recordings were collected as part of a scientific project to learn about the physiologic substrates of vocal tremor. This convenience data set contained vowels with a representative variety in vocal tremor severity. First, the vocal tremor properties in intensity level and fundamental frequency tracks were visually inspected and manually measured using Praat software. Second, the vocal tremor properties were determined using two Praat scripts: automated with the script of Maryn et al. (2019) and semi-automated with an adjusted version of this script to enable the user to intervene with the signal processing. The reliability of manual vocal tremor property measurement was assessed using the intraclass correlation coefficient. The properties as measured with the two scripts (automated vs. semi-automated) were compared with the manually determined properties using correlation and diagnostic accuracy statistical methods. RESULTS: With intraclass correlation coefficients between .770 and .914, the reliability of the manual method was acceptable. The semi-automated method correlated with manual property measures better and was more accurate in diagnosing vocal tremor than the automated method. DISCUSSION: Manual acoustic measurement of vocal tremor properties can be laborious and time-consuming. Automated or semi-automated acoustic methods may improve efficiency in vocal tremor property measurement in clinical as well as research settings. Although both Praat script-supported methods in this study yielded acceptable validity with the manual data measurements as a referent, the semi-automated method showed the best outcomes. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.28873088.

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• Misconceptions on Behavioral Cough Suppression Therapy for Pediatric Nonspecific Cough: A Response to Weinberger and Buettner’s Commentary on Fujiki et al.

  2024-04-21 · 1 citations

  preprintOpen access

  Misconceptions on Behavioral Cough Suppression Therapy for Pediatric Nonspecific Cough: A Response to Weinberger and Buettner’s Commentary on Fujiki et al.Laurie Slovarp, PhD, School of Speech, Language, Hearing, & Occupational Sciences, University of MontanaMarie Jette, PhD, Department of Otolaryngology – Head and Neck Surgery, University of Colorado Anschutz Medical CampusJane Reynolds, PhD, School of Speech, Language, Hearing, & Occupational Sciences, University of MontanaAmanda Gillespie, PhD, Department of Otolaryngology and Head and Neck Surgery, Emory UniversityJulie Barkmeier-Kraemer, PhD, Division of Otolaryngology – Head and Neck Surgery, University of UtahMary Sandage, PhD, Speech, Language, and Hearing Sciences, Auburn UniversityJaclyn Smith, PhD, Biology, Medical and Health Sciences, The University of ManchesterJemma Haines, BSc(Hons), Medical and Health Sciences, The University of Manchester, Manchester University NHS Foundation TrustAnne Vertigan, PhD, School of Medicine and Public Health, University of NewcastleStuart Mazzone, PhD, Department of Anatomy and Physiology, University of MelbourneCorresponding author: Laurie Slovarp, PhD,School of Speech, Language, Hearing, & Occupational Sciences, University of Montana, Missoula, MT, 59812. Laurie.slovarp@umontana.edu (p) 406-243-2107 (f) 406-243-2362 Orcid ID: 0000-0002-3547-4092Key words : pediatric chronic cough, habit cough, suggestion therapy, speech-language pathologyFunding : noneConflicts of Interest: The authors declare no conflicts of interest.Author Contributions :Laurie Slovarp: conceptualization, writing original draft, review and editingMarie Jette: conceptualization, writing original draft, review and editingJane Reynolds: conceptualization, writing original draft, review and editingAmanda Gillespie: conceptualization, writing original draft, review and editingJulie Barkmeier-Kraemer: review and editingMary Sandage: review and editingJaclyn Smith: review and editingJemma Haines: review and editingAnne Vertigan: review and editingStuart Mazzone: writing, review, and editingAbstract/Summary : This commentary responds to Weinberger and Buettner’s critique of Fujiki et al.’s study on behavioral cough suppression therapy (BCST) for pediatric chronic cough. While acknowledging their contributions, it addresses inaccuracies and clarifies key aspects of BCST. The commentary highlights discrepancies in terminology, challenges assertions regarding diagnostic evaluations, and emphasizes the need for controlled trials to assess treatment efficacy.In their engagement with the study by Fujiki et al.1, Weinberger and Buettner2 bring attention to critical aspects of behavioral cough suppression therapy (BCST) and pediatric chronic cough treatment. While their contributions are valued, it is imperative to address certain inaccuracies and clarify key aspects of the study and BCST provided by specialized speech-language pathologists (SLPs).Firstly, Weinberger & Buettner inaccurately state that Fujiki et al. identified the children as having ”behavioral cough.” The term ”behavioral cough” in the paper was used only in the context of ”behavioral cough suppression therapy,” describing the treatment rather than the children’s cough diagnosis. The authors, in fact, used the term ”nonspecific cough/tic cough” in accordance with current CHEST and ERS guidelines3-5. Weinberger & Buettner’s assertion that ”historical evidence and current practice support “habit cough” as the appropriate diagnosis” lacks substantiation and contradicts contemporary CHEST guidelines5. We are particularly puzzled by Weinberger & Buettner’s advocacy for the term habit cough when Dr. Weinberger is listed as an author on a 2015 CHEST guidelines publication that explicitly advises against the use of these terms, deeming them ”out of date and inaccurate”5.Weinberger & Buettner also criticize the use of extensive evaluations for the children in the sample, arguing that “habit cough” can be diagnosed based on clinical presentation alone—specifically in the presence of a barking or honking cough and absence of the cough during sleep. Interestingly, the same CHEST guidelines, of which Weinberger is an author, specifically cautions against using the diagnostic terms of “psychogenic” or “habit cough” solely based on a barking or honking sound or the absence of cough during sleep, stating that these three clinical presentations lack specificity5. A barking or honking cough can occur with other diseases such as tracheomalacia or bronchiectasis6; and it is well documented that sleep inhibits the cough reflex in adults even when an organic disease process is identified7; 8. Without evidence to the contrary, it is should be assumed that sleep similarly suppresses cough in children. Further, the purpose of Fujiki et al.’s paper was to examine whether BCST improves cough in children and to describe cough characteristics and comorbidities, not to advocate for extensive assessments. Although, it is noteworthy that laryngoscopy revealed structural laryngeal pathology in several cases, challenging Weinberger & Buettner’s assertion that the described assessments were unjustified.Regarding the treatment described in Fujiki et al., Weinberger & Buettner characterize BCST as an “alternative to suggestion therapy.” This overlooks that BCST instructs in strategies to suppress cough, akin to his “suggestion therapy.” Therefore, it seems that BCST is not necessarily an alternative but rather a similar therapy with a different name. This overlap emphasizes the need for clarity in terminology. Importantly, in adults with chronic cough a loss of centrally (brain) mediated cough suppression has been demonstrated using functional brain imaging9. Although empirical data in children is not available, it seems conceivable that similar mechanisms may be in operation, providing a neurobiological basis for why cough suppression training is often beneficial and supporting the use of terminology that emphasizes this aspect of the therapy.Additionally, Weinberger & Buettner’s argument that 45 pediatric pulmonologists ”already indicate they readily diagnose habit cough and successfully treat with suggestion therapy,” implies a stance against SLP treatment. However, considering there are thousands of pediatric pulmonologists in the U.S. alone, the sample size of 45 falls short of substantiating the claim that ”many” pulmonologists universally adopt this approach or that additional clinicians, such as SLPs, are unnecessary to assist these patients effectively. The argument lacks robust evidence and fails to account for the role of additional clinicians, such as SLPs, to address pediatric chronic cough effectively. Further, a substantial proportion of children in Fujiki et al.’s sample presented with phonotraumatic lesions (e.g., vocal nodules), which SLPs are specifically trained to address through behavioral treatment.Lastly, Weinberger & Buettner suggest that conducting a controlled trial for suggestion therapy is impractical due to the reported low frequency of referrals. We disagree that the size of the population is a valid argument for not conducting a randomized controlled trial. A control group is needed to robustly assess the efficacy of any treatment, particularly in the case of cough interventions which are particularly vulnerable to placebo effect10; 11. Weinberger & Buettner suggest that it would be unethical to withhold suggestion therapy for the sake of a randomized clinical trial; however, one could easily design a study that allowed for those randomized to a control treatment to be eligible for suggestion therapy upon completion of the control arm. Given Dr. Weinberger’s data suggests suggestion therapy eliminates nonspecific/tic cough in less than one week, such children would need to wait no more than one to two weeks before becoming eligible for suggestion therapy and it should be possible to demonstrate such a substantial effect in a relatively small number of subjects in a randomized controlled trial.We agree with Dr. Weinberger that SLP skills vary. As is the case with any clinical discipline, there are many subspecialties in the field of speech-language pathology and varying levels of skill and expertise within those subspecialties. BCST training is not standard in SLP training programs, and, therefore, requires special training.In conclusion, we think these clarifications underscore the importance of understanding Fujiki et al.’s paper in its correct context, and will advance a more nuanced and informed discussion on pediatric cough disorders and BCST’s role in treatment. We acknowledge Weinberger & Buettner’s contribution to pediatric cough management. The data reported in this letter and other publications12; 13, although anecdotal, suggests that behavioral treatment focused on cough suppression is effective. Given this, we encourage Weinberger and Buettner to complete a randomized controlled efficacy trial. If the data confirms efficacy, the study would significantly elevate the legitimacy of the treatment, increasing its use by other practitioners and benefitting pediatric patients with chronic cough.REFERENCES1. Fujiki RB, Wright ML, Fujiki AE, Thibeault SL. 2023. Factors influencing behavioral cough suppression therapy in children with nonspecific chronic cough. Pediatr Pulmonol. 58(12):3466-3477.2. Weinberger M, Buettner D. 2024. The habit cough syndrome. Pediatr Pulmonol. 59(2):260-262.3. Chang AB, Oppenheimer JJ, Irwin RS, Panel CEC. 2020. Managing chronic cough as a symptom in children and management algorithms: CHEST guideline and expert panel report. Chest. 158(1):303-329.4. Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P, Domingo Ribas C, Hilton Boon M, Kantar A, Lai K, McGarvey L et al. 2020. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J. 55(1).5. Vertigan AE, Murad MH, Pringsheim T, Feinstein A, Chang AB, Newcombe PA, Rubin BK, McGarvey LP, Weir K, Altman KW et al. 2015. Somatic cough syndrome (previously referred to as psychogenic cough) and tic cough (previously referred to as habit cough) in adults and children: CHEST guideline and expert panel report. Chest. 148(1):24-31.6. Spinou A, Lee KK, Sinha A, Elston C, Loebinger MR, Wilson R, Chung KF, Yousaf N, Pavord ID, Matos S et al. 2017. The objective assessment of cough frequency in bronchiectasis. Lung. 195(5):575-585.7. Lee KK, Birring SS. 2010. Cough and sleep. Lung. 188 Suppl 1:S91-94.8. Power JT, Stewart IC, Connaughton JJ, Brash HM, Shapiro CM, Flenley DC, Douglas NJ. 1984. Nocturnal cough in patients with chronic bronchitis and emphysema. Am Rev Respir Dis. 130(6):999-1001.9. Ando A, Smallwood D, McMahon M, Irving L, Mazzone SB, Farrell MJ. 2016. Neural correlates of cough hypersensitivity in humans: Evidence for central sensitisation and dysfunctional inhibitory control. Thorax. 71(4):323-329.10. Eccles R. 2009. Central mechanisms iv: Conscious control of cough and the placebo effect. Handb Exp Pharmacol. (187):241-262.11. Eccles R. 2010. Importance of placebo effect in cough clinical trials. Lung. 188 Suppl 1:S53-61.12. Lokshin B, Lindgren S, Weinberger M, Koviach J. 1991. Outcome of habit cough in children treated with a brief session of suggestion therapy. Ann Allergy. 67(6):579-582.13. Weinberger M, Hoegger M. 2016. The cough without a cause: Habit cough syndrome. J Allergy Clin Immunol. 137(3):930-931.

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• Misconceptions on behavioral cough suppression therapy for pediatric nonspecific cough: A response to Weinberger and Buettner's commentary on Fujiki et al.

  Pediatric Pulmonology · 2024-03-14 · 1 citations

  letter

  The authors declare no conflict of interest. The data for this study are not publicly available due to privacy and ethical restrictions.

  PublisherDOI

• The Impact of Vocal Tremor on Deglutition: A Pilot Study

  The Laryngoscope · 2024-07-04

  articleOpen access

  OBJECTIVE: Vocal tremor (VT) poses treatment challenges due to uncertain pathophysiology. VT is typically classified into two phenotypes: isolated vocal tremor (iVT) and essential tremor-related voice tremor (ETvt). The impact of phenotypes on upper aerodigestive tract physiology during swallowing remains unclear. Qualitative and quantitative measures were employed to characterize tremor phenotypes and investigate the effects on swallowing physiology. METHODS: Eleven ETvt participants (1 Male, 10 Female; x̄ age = 74) and 8 iVT participants (1 Male, 7 Female; x̄ age = 71) swallowed 20 mL boluses in cued and uncued conditions under standardized fluoroscopic visualization. Sustained/a/productions were captured to assess the rate and extent of fundamental frequency (F0) modulation. Penetration and Aspiration Scale (PAS) scores were obtained and swallowing biomechanics were captured using Swallowtail™ software. Participants also completed the Swallowing Quality of Life (SWAL-QOL) questionnaire. RESULTS: Hypopharyngeal transit was faster in both VT phenotypes compared with Swallowtail™ normative reference data. Total pharyngeal transit times, however, were only faster in patients with iVT, relative to reference data. No significant differences were observed on the SWAL-QOL or PAS between tremor phenotypes. SWAL-QOL scores revealed that these patients rarely reported dysphagia symptoms. CONCLUSIONS: Subtle differences in swallowing patterns were observed across VT phenotypes, possibly related to adaptive mechanisms resulting in quicker pharyngeal bolus transit. Most patients did not report swallowing issues or dysphagia symptoms. This study is foundational for larger studies on this challenging population. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:4599-4603, 2024.

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• A finite element model for biomechanical characterization of ex vivo peripheral nerve dysfunction during stretch

  Physiological Reports · 2024-11-01 · 3 citations

  articleOpen access

  Peripheral nerve damage can cause debilitating symptoms ranging from numbness and pain to sensory loss and atrophy. To uncover the underlying mechanisms of peripheral nerve injury, our research aims to develop a relationship between biomechanical peripheral nerve damage and function through finite element modeling. A noncontact, ex vivo electrophysiology chamber, capable of axially stretching explanted nerves while recording electrical signals, was used to investigate peripheral nerve injury. Successive stretch trials were run on eight sciatic nerves (four females and four males) excised from Sprague-Dawley rats. Nerves were stretched until 50% compound action potential (CAP) amplitude reduction was obtained. A constitutive model developed by Raghavan and Vorp was suitable for rat sciatic nerves, with an average α and β of 0.183 MPa and 1.88 MPa, respectively. We then generated 95% confidence intervals for the stretch at which specific CAP amplitude reductions would occur, which compares well to previous studies. We also developed a finite element model that can predict stretch-induced signaling deficits, applicable for complex nerve geometries and injuries. This relationship between nerve biomechanics and function can be expanded upon to create a clinical model for peripheral nerve dysfunction due to stretch.

  PublisherOA PDFDOI