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Purpose: Lexical characteristics of speech stimuli can significantly impact intelligibility. However, lexical characteristics of the widely used Speech Intelligibility Test (SIT) are unknown. We aimed to (a) define variation in neighborhood density, word frequency, grammatical word class, and type–token ratio across a large corpus of SIT sentences and tests and (b) determine the relationship of lexical characteristics to speech intelligibility in speakers with multiple sclerosis (MS), Parkinson's disease (PD), and neurologically healthy controls. Method: Using an extant database of 92 speakers (32 controls, 30 speakers with MS, and 30 speakers with PD), percent correct intelligibility scores were obtained for the SIT. Neighborhood density, word frequency, word class, and type–token ratio were calculated and summed for each of the 11 sentences of each SIT test. The distribution of each characteristic across SIT sentences and tests was examined. Linear mixed-effects models were performed to assess the relationship between intelligibility and the lexical characteristics. Results: There was large variability in the distribution of lexical characteristics across this large corpus of SIT sentences and tests. Modeling revealed a relationship between intelligibility and the lexical characteristics, with word frequency and word class significantly contributing to the model. Conclusions: Three primary findings emerged: (a) There was considerable variability in lexical characteristics both within and across the large corpus of SIT tests; (b) there was not a robust association between intelligibility and the lexical characteristics; and (c) findings from a study demonstrating an effect of neighborhood density and word frequency on intelligibility were replicated. Clinical and research implications of the findings are discussed, and three exemplar SIT tests systematically controlling for neighborhood density and word frequency are provided.

Purpose: This study investigated the effects of three clear speech variants on sentence intelligibility and speaking effort for speakers with Parkinson's disease (PD) and age- and sex-matched neurologically healthy controls. Method: Fourteen speakers with PD and 14 neurologically healthy speakers participated. Each speaker was recorded reading 18 sentences from the Speech Intelligibility Test in their habitual speaking style and for three clear speech variants: clear (SC; given instructions to speak clearly), hearing impaired (HI; given instructions to speak with someone with a hearing impairment), and overenunciate (OE; given instructions to overenunciate each word). Speakers rated the amount of physical and mental effort exerted during each speaking condition using visual analog scales (averaged to yield a metric of overall speaking effort). Sentence productions were orthographically transcribed by 50 naive listeners. Linear mixed-effects models were used to compare intelligibility and speaking effort across the clear speech variants. Results: Intelligibility was reduced for the PD group in comparison to the control group only in the habitual condition. All clear speech variants significantly improved intelligibility above habitual levels for the PD group, with OE maximizing intelligibility, followed by the SC and HI conditions. Both groups rated speaking effort to be significantly higher for both the OE and HI conditions versus the SC and habitual conditions. Discussion: For speakers with PD, all clear speech variants increased intelligibility to a level comparable to that of healthy controls. All clear speech variants were also associated with higher levels of speaking effort than habitual speech for the speakers with PD. Clinically, findings suggest that clear speech training programs consider using the instruction “overenunciate” for maximizing intelligibility. Future research is needed to identify if high levels of speaking effort elicited by the clear speech variants affect long-term sustainability of the intelligibility benefit.

Purpose: This study sought to determine the minimally detectable change (MDC) of sentence intelligibility for speakers with multiple sclerosis (MS) and Parkinson's disease (PD). Method: Speakers included 78 participants consisting of 32 neurologically healthy control speakers, 30 speakers with MS, and 16 speakers with PD. All speakers were recorded reading 11 sentences comprising the Speech Intelligibility Test (SIT), which were subsequently transcribed by inexperienced listeners. Percent correct scores were calculated for each sentence. An average percent correct score was also calculated for each speaker. The MDC at the 95% confidence interval was calculated using the following formula: MDC 95 = 1.96 × √2 × standard error of measurement. Speakers were divided into operationally defined categories of severity, and MDCs were calculated for each category to permit comparison to MDCs reported for speakers with amyotrophic lateral sclerosis (ALS). Kruskal–Wallis tests were conducted to compare MDCs between groups and severity categories. Results: The average MDC 95 for control speakers was 5.53% (range = 3.21%–7.47%) and was statistically smaller than MDCs for speakers with MS (average = 10.08%, range = 5.30%–15.62%) and those for speakers with PD (average = 10.98%, range = 8.60%–13.98%). Statistical analyses further revealed significant differences between MDCs across severity categories. Conclusions: In agreement with previous work in ALS conducted under similar conditions (i.e., orthographic transcription of SIT sentences in a quiet listening environment), the MDC 95 of speech intelligibility ranged from 3% to 10% for speakers with MS and PD who have mildly impaired speech. These estimates are a step toward the development of a universal language with which to evaluate speech changes in a variety of patient populations.

Purpose: This study investigated the criterion (analytical and clinical) and construct (divergent) validity of a novel, acoustic-based framework composed of five key components of motor control: Coordination, Consistency, Speed, Precision, and Rate. Method: Acoustic and kinematic analyses were performed on audio recordings from 22 subjects with amyotrophic lateral sclerosis during a sequential motion rate task. Perceptual analyses were completed by two licensed speech-language pathologists, who rated each subject's speech on the five framework components and their overall severity. Analytical and clinical validity were assessed by comparing performance on the acoustic features to their kinematic correlates and to clinician ratings of the five components, respectively. Divergent validity of the acoustic-based framework was then assessed by comparing performance on each pair of acoustic features to determine whether the features represent distinct articulatory constructs. Bivariate correlations and partial correlations with severity as a covariate were conducted for each comparison. Results: Results revealed moderate-to-strong analytical validity for every acoustic feature, both with and without controlling for severity, and moderate-to-strong clinical validity for all acoustic features except Coordination, without controlling for severity. When severity was included as a covariate, the strong associations for Speed and Precision became weak. Divergent validity was supported by weak-to-moderate pairwise associations between all acoustic features except Speed (second-formant [F2] slope of consonant transition) and Precision (between-consonant variability in F2 slope). Conclusions: This study demonstrated that the acoustic-based framework has potential as an objective, valid, and clinically useful tool for profiling articulatory deficits in individuals with speech motor disorders. The findings also suggest that compared to clinician ratings, instrumental measures are more sensitive to subtle differences in articulatory function. With further research, this framework could provide more accurate and reliable characterizations of articulatory impairment, which may eventually increase clinical confidence in the diagnosis and treatment of patients with different articulatory phenotypes.

Purpose The effects of neuromodulation are virtually unexplored in adductor laryngeal dystonia (AdLD), a disorder characterized by involuntary contraction of intrinsic laryngeal muscles. Recent findings indicated that intracortical inhibition is reduced in people with AdLD. Low-frequency repetitive transcranial magnetic stimulation (rTMS) induces prolonged intracortical inhibition, but the effects in AdLD are unexplored. This pilot and feasibility study aimed to examine the safety, feasibility, and effects of a single session 1 Hz rTMS over the laryngeal motor cortex (LMC) in people with AdLD and healthy individuals. Methods The stimulation location was individualized and determined through TMS-evoked responses in the thyroarytenoid muscles using fine-wire electrodes. 1200 pulses of 1 Hz rTMS were delivered to the left LMC in two groups: Control (n = 6) and AdLD (n = 7). Tolerance, adverse effects, intracortical inhibition, and voice recordings were collected immediately before and after rTMS. Voice quality was assessed with acoustic-based and auditory-perceptual measures. Results All participants tolerated the procedures, with no unexpected adverse events or worsening of symptoms. No significant effects on intracortical inhibition were observed. In the AdLD group, there was a large-effect size after rTMS in vocal perturbation measures and a small-effect size in decreased phonatory breaks. Conclusions One rTMS session over the LMC is safe and feasible, and demonstrated trends of beneficial effects on voice quality and phonatory function in AdLD. These preliminary findings support further investigation to assess clinical benefits in a future randomized sham-controlled trial. ClinicalTrials.gov NCT02957942, registered on November 8, 2016.

Purpose: The aim of this study was to use acoustic and kinematic speech measures to characterize type of motor speech impairment—apraxia of speech (AOS) versus dysarthria—in individuals with four-repeat tauopathy (4RT)–associated syndromes, including nonfluent variant primary progressive aphasia (nfvPPA), primary progressive AOS (PPAOS), corticobasal syndrome (CBS), and progressive supranuclear palsy syndrome (PSPs). Method: Twenty patient participants were recruited and stratified into two groups: (a) a motor-speech–impaired group of individuals with nfvPPA, PPAOS, CBS, or PSPs and suspected 4RT pathology (“MSI+”) and (b) a non–motor-speech-impaired group of individuals with logopenic variant primary progressive aphasia (“MSI−”). Ten healthy, age-matched controls also participated in the study. Participants completed a battery of speech tasks, and 15 acoustic and kinematic speech measures were derived. Quantitative speech measures were grouped into feature categories (“AOS features,” “dysarthria features,” “shared features”). In addition to quantitative speech measures, two certified speech-language pathologists made independent, blinded auditory-perceptual ratings of motor speech impairment. A principal component analysis (PCA) was conducted to investigate the relative contributions of quantitative features. Results: Quantitative speech measures were generally concordant with independent clinician ratings of motor speech impairment severity. Hypothesis-driven groupings of quantitative measures differentiated predominantly apraxic from predominantly dysarthric presentations within the MSI+ group. PCA results provided additional evidence for differential profiles of motor speech impairment in the MSI+ group; heterogeneity across individuals is explained in large part by varying levels of overall severity—captured by the shared feature variable group—and degree of apraxia severity, as measured by the AOS feature variable group. Conclusions: Quantitative features reveal heterogeneity of MSI in the 4RT group in terms of both overall severity and subtype of MSI. Results suggest the potential for acoustic and kinematic speech assessment methods to inform characterization of motor speech impairment in 4RT-associated syndromes. Supplemental Material: https://doi.org/10.23641/asha.21401778

Purpose: There is increasing interest in using automatic speech recognition (ASR) systems to evaluate impairment severity or speech intelligibility in speakers with dysarthria. We assessed the clinical validity of one currently available off-the-shelf (OTS) ASR system (i.e., a Google Cloud ASR API) for indexing sentence-level speech intelligibility and impairment severity in individuals with amyotrophic lateral sclerosis (ALS), and we provided guidance for potential users of such systems in research and clinic. Method: Using speech samples collected from 52 individuals with ALS and 20 healthy control speakers, we compared word recognition rate (WRR) from the commercially available Google Cloud ASR API (Machine WRR) to clinician-provided judgments of impairment severity, as well as sentence intelligibility (Human WRR). We assessed the internal reliability of Machine and Human WRR by comparing the standard deviation of WRR across sentences to the minimally detectable change (MDC), a clinical benchmark that indicates whether results are within measurement error. We also evaluated Machine and Human WRR diagnostic accuracy for classifying speakers into clinically established categories. Results: Human WRR achieved better accuracy than Machine WRR when indexing speech severity, and, although related, Human and Machine WRR were not strongly correlated. When the speech signal was mixed with noise (noise-augmented ASR) to reduce a ceiling effect, Machine WRR performance improved. Internal reliability metrics were worse for Machine than Human WRR, particularly for typical and mildly impaired severity groups, although sentence length significantly impacted both Machine and Human WRRs. Conclusions: Results indicated that the OTS ASR system was inadequate for early detection of speech impairment and grading overall speech severity. While Machine and Human WRR were correlated, ASR should not be used as a one-to-one proxy for transcription speech intelligibility or clinician severity ratings. Overall, findings suggested that the tested OTS ASR system, Google Cloud ASR, has limited utility for grading clinical speech impairment in speakers with ALS.

A sizeable group of theoretically grounded studies has defined clear speech production for neurotypical talkers as well as the perceptual consequences of neurotypical clear speech. Although less robust in size compared to the neurotypical literature, clear speech research focused on the clinical population of dysarthria has grown substantially over the last decade. The growth stems, in part, from the positive effects of clear speech on intelligibility, a perceptual construct central to the clinical management of dysarthria. We will review dysarthria research from our lab examining the effects of clear speech on speech acoustics and subsequently, on perceptual measures of speech. Factors which may contribute to variability in clear speech outcomes in dysarthria will be considered. These factors include but are not limited to (1) dysarthria neuropathology; (2) the instructions provided to elicit a clear speaking style; (3) the amount of effort exerted by the speaker; and (4) the choice of measures for evaluating efficacy. Finally, we will offer suggestions for future research that may accelerate translation of clear speech research to clinical practice.

Purpose: The purpose of this study was to investigate the association between perceived single-word speech severity and intelligibility in children with childhood apraxia of speech (CAS), with and without comorbid language impairment (LI), and to investigate the contribution of different CAS signs to perceived single-word speech severity and single-word intelligibility. Method: Thirty children with CAS, 18 with comorbid LI, completed the Goldman-Fristoe Test of Articulation–Second Edition (GFTA-2). Trained judges coded children's responses for signs of CAS and percent phonemes correct. Nine listeners, blind to diagnoses, rated speech severity using a visual analog scale. Intelligibility was assessed by comparing listeners' orthographic transcriptions of children's responses to target responses. Results: Measures of speech severity (GFTA-2 standard score, number of unique CAS signs, total CAS signs, and mean severity rating) were significantly correlated with measures of intelligibility (GFTA-2 raw score, percent phonemes correct, and mean intelligibility score). Speech severity and intelligibility did not differ significantly between children with and without LI. Only consonant errors contributed significant variability to speech severity. Consonant errors and stress errors contributed significant variability to intelligibility. Conclusions: Findings suggest that visual analog scale ratings are a valid and convenient measure of single-word speech severity and that GFTA-2 raw score is an equally convenient measure of single-word intelligibility. The result that consonant errors were by far the major contributor to single-word speech severity and intelligibility in children with CAS, with stress errors also making a small contribution to intelligibility, suggests that consonant accuracy and appropriate lexical stress should be prime therapeutic targets for these children in the context of treatment addressing motor planning/programming, self-monitoring, and self-correcting. Supplemental Material: https://doi.org/10.23641/asha.19119350

Purpose: The main purpose of this study was to create an empirical classification system for speech severity in patients with dysarthria secondary to amyotrophic lateral sclerosis (ALS) by exploring the reliability and validity of speech-language pathologists' (SLPs') ratings of dysarthric speech. Method: Ten SLPs listened to speech samples from 52 speakers with ALS and 20 healthy control speakers. SLPs were asked to rate the speech severity of the speakers using five response options: normal, mild, moderate, severe, and profound. Four severity-surrogate measures were also calculated: SLPs transcribed the speech samples for the calculation of speech intelligibility and rated the effort it took to understand the speakers on a visual analog scale. In addition, speaking rate and intelligible speaking rate were calculated for each speaker. Intrarater and interrater reliability were calculated for each measure. We explored the validity of clinician-based severity ratings by comparing them to the severity-surrogate measures. Receiver operating characteristic (ROC) curves were conducted to create optimal cutoff points for defining dysarthria severity categories. Results: Intrarater and interrater reliability for the clinician-based severity ratings were excellent and were comparable to reliability for the severity-surrogate measures explored. Clinician severity ratings were strongly associated with all severity-surrogate measures, suggesting strong construct validity. We also provided a range of values for each severity-surrogate measure within each severity category based on the cutoff points obtained from the ROC analyses. Conclusions: Clinician severity ratings of dysarthric speech are reliable and valid. We discuss the underlying challenges that arise when selecting a stratification measure and offer recommendations for a classification scheme when stratifying patients and research participants into speech severity categories.

Objective The purpose of this study was to examine the psychometric properties of an ecological vocal effort scale linked to a voicing task. Method Thirty-eight patients with nodules, 18 patients with muscle tension dysphonia, and 45 vocally healthy control individuals participated in a week of ambulatory voice monitoring. A global vocal status question was asked hourly throughout the day. Participants produced a vowel–consonant–vowel syllable string and rated the vocal effort needed to produce the task on a visual analog scale. Test–retest reliability was calculated for a subset using the intraclass correlation coefficient, ICC(A, 1). Construct validity was assessed by (a) comparing the weeklong vocal effort ratings between the patient and control groups and (b) comparing weeklong vocal effort ratings before and after voice rehabilitation in a subset of 25 patients. Cohen's d, the standard error of measurement ( SEM ), and the minimal detectable change (MDC) assessed sensitivity. The minimal clinically important difference (MCID) assessed responsiveness. Results Test–retest reliability was excellent, ICC(A, 1) = .96. Weeklong mean effort was statistically higher in the patients than in controls ( d = 1.62) and lower after voice rehabilitation ( d = 1.75), supporting construct validity and sensitivity. SEM was 4.14, MDC was 11.47, and MCID was 9.74. Since the MCID was within the error of the measure, we must rely upon the MDC to detect real changes in ecological vocal effort. Conclusion The ecological vocal effort scale offers a reliable, valid, and sensitive method of monitoring vocal effort changes during the daily life of individuals with and without vocal hyperfunction.

The effects of neuromodulation are virtually unexplored in adductor laryngeal dystonia (AdLD), a disorder characterized by involuntary contraction of intrinsic laryngeal muscles. Recent findings indicated that intracortical inhibition is reduced in people with AdLD. Low-frequency repetitive transcranial magnetic stimulation (rTMS) induces prolonged intracortical inhibition, but the effects in AdLD are unexplored. This pilot and feasibility study aimed to examine the safety, feasibility, and effects of a single session 1 Hz rTMS over the laryngeal motor cortex (LMC) in people with AdLD and healthy individuals.The stimulation location was individualized and determined through TMS-evoked responses in the thyroarytenoid muscles using fine-wire electrodes. 1200 pulses of 1 Hz rTMS were delivered to the left LMC in two groups: Control (n = 6) and AdLD (n = 7). Tolerance, adverse effects, intracortical inhibition, and voice recordings were collected immediately before and after rTMS. Voice quality was assessed with acoustic-based and auditory-perceptual measures.All participants tolerated the procedures, with no unexpected adverse events or worsening of symptoms. No significant effects on intracortical inhibition were observed. In the AdLD group, there was a large-effect size after rTMS in vocal perturbation measures and a small-effect size in decreased phonatory breaks.One rTMS session over the LMC is safe and feasible, and demonstrated trends of beneficial effects on voice quality and phonatory function in AdLD. These preliminary findings support further investigation to assess clinical benefits in a future randomized sham-controlled trial. CLINICALTRIALS.GOV: NCT02957942, registered on November 8, 2016.

Objective: Understanding clinical variants of motor neuron diseases such as amyotrophic lateral sclerosis (ALS) is critical for discovering disease mechanisms and across-patient differences in therapeutic response. The current work describes two clinical subgroups of patients with ALS that, despite similar levels of bulbar motor involvement, have disparate clinical and functional speech presentations.Methods: Participants included 47 healthy control speakers and 126 speakers with ALS. Participants with ALS were stratified into three clinical subgroups (i.e., bulbar asymptomatic, bulbar symptomatic high speech function, and bulbar symptomatic low speech function) based on clinical metrics of bulbar motor impairment. Acoustic and lip kinematic analytics were derived from each participant's recordings of reading samples and a rapid syllable repetition task. Group differences were reported on clinical scales of ALS and bulbar motor severity and on multiple speech measures.Results: The high and low speech-function subgroups were found to be similar on many of the dependent measures explored. However, these two groups were differentiated on the basis of an acoustic measure used as a proxy for tongue movement.Conclusion: This study supports the hypothesis that high and low speech-function subgroups do not differ solely in overall severity, but rather, constitute two distinct bulbar motor phenotypes. The findings suggest that the low speech-function group exhibited more global involvement of the bulbar muscles than the high speech-function group that had relatively intact lingual function. This work has implications for clinical measures used to grade bulbar motor involvement, suggesting that a single bulbar measure is inadequate for capturing differences among phenotypes.

Sustained limb motor activity has been used as a therapeutic tool for improving rehabilitation outcomes and is thought to be mediated by neuroplastic changes associated with activity-induced cortical excitability. Although prior research has reported enhancing effects of continuous chewing and swallowing activity on learning, the potential beneficial effects of sustained oromotor activity on speech improvements is not well-documented. This exploratory study was designed to examine the effects of continuous oromotor activity on subsequent speech learning. Twenty neurologically healthy young adults engaged in periods of continuous chewing and speech after which they completed a novel speech motor learning task. The motor learning task was designed to elicit improvements in accuracy and efficiency of speech performance across repetitions of eight-syllable nonwords. In addition, transcranial magnetic stimulation was used to measure the cortical silent period (cSP) of the lip motor cortex before and after the periods of continuous oromotor behaviors. All repetitions of the nonword task were recorded acoustically and kinematically using a three-dimensional motion capture system. Productions were analyzed for accuracy and duration, as well as lip movement distance and speed. A control condition estimated baseline improvement rates in speech performance. Results revealed improved speech performance following 10 min of chewing. In contrast, speech performance following 10 min of continuous speech was degraded. There was no change in the cSP as a result of either oromotor activity. The clinical implications of these findings are discussed in the context of speech rehabilitation and neuromodulation.

X-linked Dystonia-Parkinsonism (XDP) is a progressive, disabling disease characterized by the devastating impairment of bulbar function, including speech and swallowing. Despite these detrimental impacts, bulbar impairments in this population are not well characterized.To identify impairments in the bulbar system measured by oromotor performance in individuals with XDP relative to healthy controls. Secondarily, to detect diagnostic bulbar markers that are sensitive and specific to the initial years of XDP.This case-control study included 25 healthy controls and 30 participants with XDP, divided into two subgroups based on the median of their disease length. Multiple clinical and instrumental oromotor tasks and measures were used to evaluate bulbar motor function.Differences were found between both the subgroups with XDP and healthy controls on almost all measures, including maximum performance tasks such as tongue strength, alternating motion rate (AMR), and sequential motion rate (SMR) (p 0.05). Differences were found between the XDP subgroups and the control group for the percentage of pause time during the speech, a rating of speech severity, and a swallowing task (ps 0.05). Scores on self-reported questionnaires, tongue strength, the number of repetitions produced during an AMR, percent pause, and speech severity demonstrated good sensitivity and specificity to differentiate the initial years of XDP onset from healthy controls.Our findings revealed impairments across bulbar functions in participants within the first 7 years of the XDP onset. Highly sensitive and specific bulbar impairment measures were detected in instrumental and self-reported measures that are fundamental for monitoring disease.

Introduction Jaw movement during chewing and speech is facilitated by neural activation patterns for opening and closing movements of the mandible. This study investigated anatomic- and task-dependent differences in intermuscular coherence (IMC) and their association with the parameters of jaw muscle activity using surface electromyography (sEMG). Methods We recorded sEMG activation from bilateral and ipsilateral jaw-closing muscle pairs during non-nutritive and nutritive chewing, and during a syllable repetition task. IMC and cross-correlational analyses between bilateral and ipsilateral muscle pairs were performed. Results Intermuscular coherence in the beta band was statistically significant between agonist jaw-closing muscle pairs, with beta IMC weaker for rapid syllable repetition compared to chewing tasks. Cross-correlational analysis of muscle co-activation, as well as sEMG burst amplitude, was positively associated with beta IMC strength. Discussion Beta IMC was influenced heavily by task-dependent behavioral goals and physiologic demands, which was interpreted as evidence of shared neural drive among jaw-closing muscles.

Purpose The high incidence of swallowing and communication disorders following stroke is well documented. However, many of these studies have used retrospective chart reviews to make estimates of incidence and co-occurrence. The current study prospectively examined the incidence and co-occurrence of dysphagia, dysarthria, and aphasia following a 1st occurrence of ischemic stroke at an academic medical center hospital. Method One hundred patients who experienced their 1st ischemic stroke were recruited for participation in this study. All participants received a clinical swallowing evaluation to assess for dysphagia, administration of the Frenchay Dysarthria Assessment–Second Edition ( Enderby & Palmer, 2008 ) and Western Aphasia Battery–Revised ( Kertesz, 2006 ) to screen for the presence of dysarthria and aphasia, respectively. Results Incidence rates of dysphagia, dysarthria, and aphasia were 32%, 26%, and 16%, respectively. Forty-seven percent of participants had at least 1 of these disorders, 28% had 2 of these disorders, and 4% had all 3. Although the incidence rates in this study were smaller in magnitude than incidence rates in previous research, the pattern of results is broadly similar (i.e., dysphagia had the highest incidence rate, followed by dysarthria and, lastly, aphasia). Conclusions This prospective study yielded slightly lower incidence rates than have been previously obtained from retrospective chart reviews. The high incidence and co-occurrence of devastating swallowing and communication disorders post–ischemic stroke provides clear motivation for speech-language pathology involvement in the early phase of stroke rehabilitation.

Introduction: Universally established comprehensive clinical bulbar scales objectively assessing disease progression in amyotrophic lateral sclerosis (ALS) are currently lacking. The goal of this working group project is to design a best practice set of provisional bulbar ALS guidelines, available for immediate implementation within all ALS clinics. Methods: ALS specialists across multiple related disciplines participated in a series of clinical bulbar symposia, intending to identify and summarize the currently accepted best practices for the assessment and management of bulbar dysfunction in ALS Results: Summary group recommendations for individual speech, Augmentative and Alternative Communication (AAC), and swallowing sections were achieved, focusing on the optimal proposed level of care within each domain. Discussion: We have identified specific clinical recommendations for each of the 3 domains of bulbar functioning, available for incorporation within all ALS clinics. Future directions will be to establish a formal set of bulbar guidelines through a methodological and evidence-based approach. Muscle Nerve 59:531–531, 2019. Fil: Pattee, Gary L.. No especifíca; Fil: Plowman, Emily K.. University of Florida; Estados Unidos Fil: Garand, Kendrea L.. University of Alabama at Birmingahm; Estados Unidos Fil: Costello, John. No especifíca; Fil: Brooks, Benjamin Rix. No especifíca; Fil: Berry, James D.. No especifíca; Fil: Smith, Richard A.. No especifíca; Fil: Atassi, Nazem. No especifíca; Fil: Chapin, Jennifer L.. University of Florida; Estados Unidos Fil: Yunusova, Yana. University of Toronto; Canadá Fil: McIlduff, Courtney E.. No especifíca; Fil: Young, Eufrosina. No especifíca; Fil: Macklin, Eric A.. No especifíca; Fil: Locatelli, Eduardo R.. No especifíca; Fil: Silani, Vincenzo. Università degli Studi di Milano; Italia Fil: Heitzman, Daragh. No especifíca; Fil: Wymer, James. University of Florida; Estados Unidos Fil: Goutman, Stephen A.. No especifíca; Fil: Gelinas, Deborah F.. No especifíca; Fil: Perry, Bridget. No especifíca; Fil: Nalipinski, Paige. No especifíca; Fil: Stipancic, Kaila. Children's Hospital Boston; Estados Unidos Fil: O'Brien, Meghan. Children's Hospital Boston; Estados Unidos Fil: Sullivan, Stacey L.. No especifíca; Fil: Pioro, Erik P.. No especifíca; Fil: Gargiulo Monachelli, Gisella Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET; Argentina Fil: Green, Jordan R.. No especifíca

Purpose The purpose of this study was to determine the minimally detectable change (MDC) and minimal clinically important difference (MCID) of a decline in speech sentence intelligibility and speaking rate for individuals with amyotrophic lateral sclerosis (ALS). We also examined how the MDC and MCID vary across severities of dysarthria. Method One-hundred forty-seven patients with ALS and 49 healthy control subjects were selected from a larger, longitudinal study of bulbar decline in ALS, resulting in a total of 650 observations. Intelligibility and speaking rate in words per minute (WPM) were calculated using the Sentence Intelligibility Test (Yorkston, Beukelman, & Hakel, 2007), and the ALS Functional Rating Scale–Revised (Cedarbaum et al., 1999) was administered to capture patient perception of motor impairment. The MDC at the 95% confidence level was estimated using the following formula: MDC 95 = 1.96 × √2 × SEM . For estimation of the MCID, receiver operating characteristic curves were generated, and area under the curve and optimal thresholds to maximize sensitivity and specificity were calculated. Results The MDC for sentence intelligibility was 12.07%, and the MCID was 1.43%. The MDC for speaking rate was 36.57 WPM, and the MCID was 8.80 WPM. Both MDC and MCID estimates varied with severity of dysarthria. Conclusions The findings suggest that declines greater than 12% sentence intelligibility and 37 WPM are required to be outside measurement error and that these estimates vary widely across dysarthria severities. The MDC and MCID metrics used in this study to detect real and clinically relevant change should be estimated for other measures of speech outcomes in intervention research.

Objective: The use of speech measures is becoming a common practice in the assessment of bulbar disease progression in amyotrophic lateral sclerosis (ALS). This study aimed to establish psychometric properties (e.g. reliability, validity, sensitivity, specificity) of speech and pause timing measures during a standardized passage. Methods: A large number of passage recordings (ALS N = 775; Neurotypical controls N = 323) was analyzed using a semi-automatic method (Speech and Pause Analysis, SPA). Results: The results revealed acceptable reliability of the speech and pause measures across repeated recording by the control participants. Strong construct validity was established via significant group differences between patients and controls and correlation statistics with clinical measures of overall ALS and bulbar disease severity. Speaking rate, pause events, and mean pause duration were able to detect ALS participants at the presymptomatic stage of bulbar disease with a good discrimination ability (AUC 0.81). Conclusions: Based on the current psychometric evaluation, performing passage recording and speech and pause timing analysis was deemed useful for detecting early and progressive changes associated with bulbar ALS.

Alternating motion rate (AMR) is a standard measure often included in neurological examinations to assess orofacial neuromuscular integrity. AMR is typically derived from recordings of patients producing repetitions of a single syllable as fast and clear as possible on one breath. Because the task places high demands on oromotor performance, particularly articulatory speed, AMRs are widely considered to be tests of maximum performance and, therefore, likely to reveal underlying neurologic deficits. Despite decades of widespread use, biomechanical studies have shown that speakers often circumvent the presumed speed challenge of the standard AMR task. Specifically, speakers are likely to manipulate their displacements (movement amplitude) instead of speed because this strategy requires less motor effort. The current study examined the effectiveness of a novel fixed-target paradigm for minimizing the truncation of articulatory excursions and maximizing motor effort. We compared the standard AMR task to that of a fixed-target AMR task and focused specifically on the tasks' potential to detect decrements in lip motor performance in persons with dysarthria due to amyotrophic lateral sclerosis (ALS). Our participants were 14 healthy controls and 17 individuals with ALS. For the standard AMR task, participants were instructed to produce the syllable /bα/ as quickly and accurately as possible on one breath. For the fixed-target AMR task, participants were given the same instructions, but were also required to strike a physical target placed under the jaw during the opening phase of each syllable. Lip kinematic data were obtained using 3D electromagnetic articulography. 16 kinematic features were extracted using an algorithmic approach. Findings revealed that compared to the standard task, the fixed-target AMR task placed increased motor demands on the oromotor system by eliciting larger excursions, faster speeds, and greater spatiotemporal variability. In addition, participants with ALS exhibited limited ability to adapt to the higher articulatory demands of the fixed-target task. Between the two AMR tasks, the maximum speed during the fixed-target task showed a moderate association with the ALSFRS-R bulbar subscore. Employment of both standard and fixed-target AMR tasks is, however, needed for comprehensive assessment of oromotor function and for elucidating profiles of task adaptation.

BACKGROUND. The impact of tongue dysfunction on deglutition in persons diagnosed with amyotrophic lateral sclerosis (ALS) is not well understood. This information is needed to improve our understanding of the mechanisms of swallowing impairment, for identifying risk factors of dysphagia, and for establishing impairment-specific treatments aimed at slowing the loss of swallow function. OBJECTIVES. The goals of this study were to determine the relation between biomechanical measures of oral tongue movements using electromagnetic articulography (EMA) and measures of swallow physiology, swallow safety and efficiency, and self-reported swallowing function. METHODS. Participants were diagnosed with ALS by a neurologist following the El Escorial Criteria from the World Federation of Neurology. Twelve participants underwent 1) EMA to derive biomechanical measures of the tongue, 2) videofluoroscopic evaluation to measure swallow physiology, safety, and efficiency, and 3) maximal tongue strength testing using the Iowa Oral Pressure Instrument (IOPI). Participants completed self-reported functional assessments. Spearman’s rank correlations assessed for associations between lingual biomechanics and swallowing physiology, swallow safety and efficiency, and self-reported bulbar function. RESULTS. Results demonstrated strong associations between biomechanical and swallowing physiology, swallow safety, and self-reported measures. Notably, swallowing safety during thin liquid intake was associated with tongue speed (r=−.7, p

Purpose This study obtained judgments of sentence intelligibility using orthographic transcription for comparison with previously reported intelligibility judgments obtained using a visual analog scale (VAS) for individuals with Parkinson's disease and multiple sclerosis and healthy controls (K. Tjaden, J. E. Sussman, & G. E. Wilding, 2014). Method Speakers read Harvard sentences in habitual, clear, loud, and slow conditions. Sentence stimuli were equated for peak intensity and mixed with multitalker babble. A total of 50 listeners orthographically transcribed sentences. Procedures were identical to those for a VAS reported in Tjaden, Sussman, and Wilding (2014). Results The percent correct scores from transcription were significantly higher in magnitude than the VAS scores. Multivariate linear modeling indicated that the pattern of findings for transcription and VAS was virtually the same with respect to differences among groups and speaking conditions. Correlation analyses further indicated a moderately strong, positive relationship between the two metrics. The majority of these correlations were significant. Last, intrajudge and interjudge listener reliability metrics for the two intelligibility tasks were comparable. Conclusion Results suggest that there may be instances when the less time-consuming VAS task may be a viable substitute for an orthographic transcription task when documenting intelligibility in mild dysarthria.

OBJECTIVES/SPECIFIC AIMS: Using a novel biomechanical-based motor speech assessment alongside commonly used clinically-based motor speech assessments, the goal of this study was to describe longitudinal recovery in speech movements and functional speech in a cohort of 5 patients following facial transplantation. METHODS/STUDY POPULATION: Five participants who had received either full or partial face transplantation were included in this study. Each participant received a unique facial graft from their donor, which included varied amounts of soft tissue, facial musculature, nerve, and bone. Two participants were early in the recovery period and were assessed from zero to 24 months post-transplantation. Three participants were late in the recovery period and were assessed from 36 to 60 months post-transplantation. Each participant completed two data collection sessions and the average time between sessions was 20.4 months. At each session, orofacial movements were recorded using a 3D motion capture system. A 4-sensor head marker was used to subtract head movement (translation and rotation) from the facial markers. The analyses in this study were restricted to two markers: midline lower lip and a virtually calculated midline jaw marker. A marker at the top of the nose bridge was used as the origin point. The following kinematic variables were obtained from each lip-jaw movement time-series: peak movement speed (mm/s), and displacement (mm). Each patient was instructed to perform 10 repetitions of the phrase “buy bobby a puppy” at his or her typical speaking rate and volume. Sentence-level intelligibility was obtained using the Sentence Intelligibility Test (SIT) and word-level intelligibility was obtained using the Word Intelligibility Test, using standard procedures. Intelligibility, measured in percentage of words correctly transcribed, and speaking rate, measured in words per minute (wpm), was derived from the SIT sentences for each patient. Intelligibility, measured in percentage of words correctly chosen via multiple choice was derived from the Word Intelligibility Test. RESULTS/ANTICIPATED RESULTS: Effect sizes (Cohen’s d) across the 10 trials of “buy bobby a puppy” were computed to assess the effects of recovery time on range of motion and speed of the lower lip alone, the jaw alone, and the lower lip and jaw together for both range of motion and for speed. The largest effect sizes were observed for increased range of motion and increased speed of the articulators for participants within 24 months of surgery. Smaller effect sizes were observed for these parameters for the participants in the later stages of recovery, with some participants showing declines in range of motion and speed of some but not all articulators. Descriptive statistics indicate that both speech and word intelligibility improvements are most notable in the first two years following transplantation and appear to plateau during the later stages of recovery. Only two out of five of our participants achieved “normal” speech intelligibility (i.e., >97%) at five years post-transplantation. DISCUSSION/SIGNIFICANCE OF IMPACT: Biomechanical assessment revealed that kinematic recovery of articulator range of motion and speed appears most significant in the first two years following surgery, but that improvement continues to some degree as far as five-years post-transplant. Clinically-based assessments suggest that gains in intelligibility appear to plateau by 3-years post-surgery.

The aim of this Symposium was to develop a consensus based, bulbar assessment protocol for implementation within NEALS clinics.A one-day symposium, held in April 2017, was organized into Speech and Swallowing sections to establish summary recommendations for the assessment of bulbar dysfunction within each group.Summary recommendations included speech referrals and AAC evaluations at initial visit, CNS-BFS, maximum sustained phonation, and speaking rate. Dysarthria evaluation included the speech subsystem involvement of respiration, phonation, resonance, and articulation. Specific recommendations for swallowing were established for each of the following domains: dietary/oral intake, airway defense physiologic capacity, swallow safety screen, patient-reported swallow-related outcomes, oral sensorimotor exam, and pulmonary function. Practice parameters focused upon patient education and unresolved questions included the use of videofluoscopy, monitoring diet progression, and swallow safety screening.The working goal is to establish a clinical bulbar protocol, designed to be incorporated within ALS clinics and ultimately to formulate a best practice set of bulbar ALS guidelines, available for implementation throughout the international ALS community.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by loss of muscle strength and function. The speech systems (respiratory, phonatory, velopharyngeal, and articulatory) are frequently affected, causing speech and swallowing impairments. Changes to voice production are often reported. These changes include altered fundamental frequency, phonatory instability, and the development of breathy or harsh voice quality (see Green et al., 2013 for review). While acoustic studies of speakers with ALS have demonstrated voice dysfunction, the findings have been variable in the type and direction of change across individual speakers. The current investigation seeks to further explicate vocal dysfunction and change in ALS by exploring promising acoustic phonatory measures across disease progression. Participants with and without ALS were audiorecorded at multiple time points while producing sustained vowels and connected speech. Acoustic analyses include traditional phonatory measures extracted from vowel prolongations (fundamental frequency, jitter, and shimmer) and newer measures of phonation across connected speech (e.g., cepstral peak prominence). Voice metrics are compared between speaker groups and across time points. It is anticipated that the findings will support the development of valid and reliable measures to mark disease onset and progression, thereby facilitating intervention and mitigating the devastating impact of ALS.Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by loss of muscle strength and function. The speech systems (respiratory, phonatory, velopharyngeal, and articulatory) are frequently affected, causing speech and swallowing impairments. Changes to voice production are often reported. These changes include altered fundamental frequency, phonatory instability, and the development of breathy or harsh voice quality (see Green et al., 2013 for review). While acoustic studies of speakers with ALS have demonstrated voice dysfunction, the findings have been variable in the type and direction of change across individual speakers. The current investigation seeks to further explicate vocal dysfunction and change in ALS by exploring promising acoustic phonatory measures across disease progression. Participants with and without ALS were audiorecorded at multiple time points while producing sustained vowels and connected speech. Acoustic analyses include traditional phonatory measures ext...