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Ataxic dysarthria: Treatment sequences based on intelligibility and prosodic considerations
Abstract
Treatment programs of four improving ataxic dysarthric speakers are reviewed. Treatment sequences were based on two overall measures of speech performance-intelligibility and prosody. Increases in intelligibility were initially achieved by control of speaking rate. A hierarchy of rate control strategies, ranging from a rigid imposition of rate through thythmic cueing to self-monitored rate control is discussed. As speakers improved their monitoring skills, a compromise was made between intelligibility and rate. Normal prosodic patterns were not achieved by the ataxic speakers due to difficulty in precisely coordinating the subtle fundamental frequency, loudness and timing adjustments needed to signal stress. Three of the four subjects were taught to use only durational adjustments to signal stress. In this way, they were able to achieve stress on targeted words consistently and minimize bizarreness which resulted from sweeping changes in fundamental frequency and bursts of loudness. The need for further clinically oriented research is discussed.
... The literature on stress production in populations with motor speech disorders has focused both on characterizing the problems these speakers experience with lexical or sentence stress production as well as investigating treatment effects. Both developmental and acquired disorders have been studied, including cerebral palsy (CP) (Patel and Campellone 2009), traumatic or other types of brain injury (McHenry 1998, Simmons 1983, Wang et al. 2005, Yorkston and Beukelman 1981, Yorkston et al. 1984), Parkinson's disease (Cheang and Pell 2007, Darkins et al. 1988, Gaviria 2015, Tykalova et al. 2014, multiple sclerosis (Hartelius et al. 1997), different types of ataxia (Liss and Weismer 1994, Lowit et al. 2010, and foreign accent syndrome (Kuschmann and Lowit 2012). In terms of dysarthria types, the two most widely studied groups are ataxic and hypokinetic dysarthria. ...
... The results suggest that this might be the case based on the results of the 150% F0 increase paradigm, however, no information is available on the other parameters or the AMP utterance set. Reports from the literature also suggest that this could be the case, e.g., Yorkston and Beukelman (1981) report that one of their speakers who exaggerated intensity increases was 100% successful in signalling stress target position. At the same time, they raise concerns about the bizarreness ratings of the speaker. ...
... In addition, some of the exaggerated productions that are frequently elicited from clients in clinic are also often perceived as unnatural, and listeners' reactions might thus be similar to our digitally manipulated and naturally produced utterances (cf. Yorkston and Beukelman 1981). ...
Background
Stress production is important for effective communication, but this skill is frequently impaired in people with motor speech disorders. The literature reports successful treatment of these deficits in this population, thus highlighting the therapeutic potential of this area. However, no specific guidance is currently available to clinicians about whether any of the stress markers are more effective than others, to what degree they have to be manipulated, and whether strategies need to differ according to the underlying symptoms.
Aims
In order to provide detailed information on how stress production problems can be addressed, the study investigated (1) the minimum amount of change in a single stress marker necessary to achieve significant improvement in stress target identification; and (2) whether stress can be signalled more effectively with a combination of stress markers.
Methods & Procedures
Data were sourced from a sentence stress task performed by 10 speakers with ataxic dysarthria and 10 healthy matched control participants. Fifteen utterances perceived as having incorrect stress patterns (no stress, all words stressed or inappropriate word stressed) were selected and digitally manipulated in a stepwise fashion based on typical speaker performance. Manipulations were performed on F0, intensity and duration, either in isolation or in combination with each other. In addition, pitch contours were modified for some utterances. A total of 50 naïve listeners scored which word they perceived as being stressed.
Outcomes & Results
Results showed that increases in duration and intensity at levels smaller than produced by the control participants resulted in significant improvements in listener accuracy. The effectiveness of F0 increases depended on the underlying error pattern. Overall intensity showed the most stable effects. Modifications of the pitch contour also resulted in significant improvements, but not to the same degree as amplification. Integration of two or more stress markers did not result in better results than manipulation of individual stress markers, unless they were combined with pitch contour modifications.
Conclusions & Implications
The results highlight the potential for improvement of stress production in speakers with motor speech disorders. The fact that individual parameter manipulation is as effective as combining them will facilitate the therapeutic process considerably, as will the result that amplification at lower levels than seen in typical speakers is sufficient. The difference in results across utterance sets highlights the need to investigate the underlying error pattern in order to select the most effective compensatory strategy for clients.
... En clinique, les orthophonistes évaluent généralement l'intelligibilité de la parole, décrite comme le degré auquel le locuteur est compris par son interlocuteur (Yorkston & Beukelman, 1981). L'intelligibilité est un paramètre intéressant pour l'évaluation de la dysarthrie secondaire à la SCP puisqu'elle indique la fonctionnalité de la parole; la personne peut-elle se faire comprendre ? ...
... Les mesures du débit et de la prosodie peuvent être évaluées en termes de vitesse, de rythme ou de patron d'intonation (Yorkston, 1999). Ces composantes de la parole possèdent une relation très forte avec l'intelligibilité; si un patient parle trop vite, le locuteur ne comprendra pas ce qu'il dit, s'il ralentit, l'intelligibilité sera beaucoup mieux (Yorkston & Beukelman, 1981 Parmi les nombreuses mesures mentionnées comme étant valides pour l'évaluation de la dysarthrie, la mesure du débit est retenue puisqu'elle peut être obtenue simplement en chronométrant la production de 20 syllabes (Kent et coll., 2000). La tâche de répétition de syllabes rapide sera administrée avec les cibles /pa-ta-ka/, /pa/ et /ka/. ...
La stimulation cérébrale profonde des noyaux sous-thalamiques utilisée dans le traitement des symptômes moteurs de la maladie de Parkinson engendre fréquemment des effets secondaires sur l’intelligibilité de la parole. Aucune évaluation objective de la parole n’est actuellement administrée lors de la chirurgie d’implantation des électrodes malgré que le site de contact des électrodes influence grandement les résultats
postopératoires. L’objectif de cette revue systématique des écrits scientifiques est de documenter et d’identifier les éléments pertinents pour prendre position quant à une procédure d’évaluation de la parole applicable au contexte peropératoire de
stimulation cérébrale profonde dans la maladie de Parkinson. Grâce à une recherche effectuée sur les bases de données Medline, Cinahl et Google Scholar, 28 articles ont été analysés et de courtes tâches de répétition de mots, de répétition de syllabes rapide, de tenue vocalique et d’auto-évaluation ont été retenues. Ces quatre tâches permettent d’évaluer les effets directs du site d’implantation pour la stimulation sur la
parole grâce aux mesures acoustiques, soit le temps maximal de phonation, la pente de transition du F2 et le débit articulatoire. Cette revue a permis d’identifier un protocole d’évaluation qui pourrait guider la pratique clinique.
... 20 Bilateral structural abnormalities (e.g., increased or reduced gray matter) were found to limit this functional reorganization, thus contributing to poor prognosis. Dysarthria is broadly defi ned by fi ve classifi cations, which include fl accid, 21 spastic, 22 hyperkinetic/hypokinetic, 23,24 ataxic, 25 and mixed 26 dysarthrias, all of which have been reported following TBI. The most common types include spastic 27 and mixed (e.g., spastic-ataxic) subtypes, which is not surprising given the diffuse bilateral hemispheric damage, and the common involvement of the frontal lobes 28 and cerebellum, due to contracoup injuries. ...
... Impaired vocal loudness, imprecise articulation, hypernasality, mono-pitch, and speech rate can be the features of dysarthria [13,14]. Previous studies on the treatment of ataxic dysarthria have focused mainly on respiratory control, modification of rate, and loudness or pitch control, and positive responses to these techniques have been reported in the literature [15,16]. However, Vogel et al. [17], reviewed the effects of interventions for speech disorders in adults and children with Friedreich ataxia and other hereditary ataxias. ...
Objective: In this case report, we aimed to examine the effects of an intensive voice treatment (the Lee Silverman Voice Treatment [LSVT®LOUD]) for Wilson’s disease (WD), and adult cerebral palsy (CP), and dysarthria.
Method: The participants received LSVT®LOUD four times a week for 4 weeks. Acoustic, perceptual (GRBAS) analyses were performed and data from the Voice Handicap Index (VHI) were obtained before and after treatment.
Results: Besides the Harmonics-to Noise Ratio (HNR) value (dB) of the participant with WD, for both participants’ fundamental frequencies (Hz), jitter (%), and shimmer (%) values showed significant differences (p < .05) after therapy. Both participants showed significant improvements (p < .05) in the duration (s) and the sound pressure level (dB, SPL) of sustained vowel phonation (/a/), in SPL (dB) of pitch range (high and low /a/) and reading and conversation (p < .01). There was a positive improvement in the high-frequency values (Hz) of both participants but not in the low-frequency values (Hz) in the participant with WD. Perceptual analysis with GRBAS judgements of sustained vowel (/a/) and paragraph reading of two participants also showed improvement. After therapy, perceived loudness of the participants’ voice increased.
Conclusions: The findings provide some preliminary observations that the individuals with WD and the adult individuals with CP can respond positively to intensive speech treatment such as LSVT®LOUD. Further studies are needed to investigate speech treatments specific to WD and adult CP.
... This statement was supported by Martens et al. (2015) who investigated the effect of intensive treatment of speech rate and intonation on the intelligibility of dysarthric patients due to Parkinson's disease and observed significant improvements of the intelligibility scores. Other studies where rate control techniques were investigated found similar effects (Yorkston and Beukelman 1981, Marcella et al. 1998, Hustad et al. 2003. In addition, other behavioural therapy techniques seem to have a positive impact on intelligibility as well. ...
Background
The articulatory accuracy of patients with dysarthria is one of the most affected speech dimensions with a high impact on speech intelligibility. Behavioural treatments of articulation can either involve direct or indirect approaches. The latter have been thoroughly investigated and are generally appreciated for their almost immediate effects on articulation and intelligibility. The number of studies on (short‐term) direct articulation therapy is limited.
Aims
To investigate the effects of short‐term, boost articulation therapy (BArT) on speech intelligibility in patients with chronic or progressive dysarthria and the effect of severity of dysarthria on the outcome.
Methods & Procedures
The study consists of a two‐group pre‐/post‐test design to assess speech intelligibility at phoneme and sentence level and during spontaneous speech, automatic speech and reading a phonetically balanced text. A total of 17 subjects with mild to severe dysarthria participated in the study and were randomly assigned to either a patient‐tailored, intensive articulatory drill programme or an intensive minimal pair training. Both training programmes were based on the principles of motor learning. Each training programme consisted of five sessions of 45 min completed within one week.
Outcomes & Results
Following treatment, a statistically significant increase of mean group intelligibility was shown at phoneme and sentence level, and in automatic sequences. This was supported by an acoustic analysis that revealed a reduction in formant centralization ratio. Within specific groups of severity, large and moderate positive effect sizes with Cohen's d were demonstrated.
Conclusions & Implications
BArT successfully improves speech intelligibility in patients with chronic or progressive dysarthria at different levels of the impairment.
What this paper adds
What is already known on the subject
• Behavioural treatment of articulation in patients with dysarthria mainly involves indirect strategies, which have shown positive effects on speech intelligibility. However, there is limited evidence on the short‐term effects of direct articulation therapy at the segmental level of speech. This study investigates the effectiveness of BArT on speech intelligibility in patients with chronic or progressive dysarthria at all severity levels.
What this paper adds to existing knowledge
• The intensive and direct articulatory therapy programmes developed and applied in this study intend to reduce the impairment instead of compensating it. This approach results in a significant improvement of speech intelligibility at different dysarthria severity levels in a short period of time while contributing to exploit and develop all available residual motor skills in persons with dysarthria.
What are the potential or actual clinical implications of this work?
• The improvements in intelligibility demonstrate the effectiveness of a BArT at the segmental level of speech. This makes it to be considered a suitable approach in the treatment of patients with chronic or progressive dysarthria.
... Slow speech, in contrast, tends to elicit larger articulatory displacement, slower movement speed, and longer movement duration (26,27). Some research suggests that the longer duration associated with slow speech enhances articulatory precision (28,29) or phoneme distinctiveness (9,(30)(31)(32) and improves speech intelligibility (33,34); however, findings are mixed. Several studies have found that slow speech did not promote more precise articulation, but rather clear speech allowed speakers to maintain control over jaw opening movements and improved speech intelligibility (10,35). ...
Despite signs of facial nerve recovery within a few months following face transplantation, speech deficits persist for years. Behavioral speech modifications (e.g., slower-than-normal speaking rate and increased loudness) have shown promising potential to enhance speech intelligibility in populations with dysarthric speech. However, such evidence-based practice approach is lacking in clinical management of speech in individuals with facial transplantation. Because facial transplantation involves complex craniofacial reconstruction and facial nerve coaptation, it is unknown to what extent individuals with face transplant are capable of adapting their motor system to task-specific articulatory demands. The purpose of this study was to identify the underlying articulatory mechanisms employed by individuals with face transplantation in response to speech modification cues at early and late stages of neuromotor recovery. In addition, we aimed to identify speech modifications that conferred improved speech clarity. Participants were seven individuals who underwent full or partial facial vascularized composite allografts that included lips and muscles of facial animation and were in early (~2 months) or late (~42 months) stages of recovery. Participants produced repetitions of the sentence “Buy Bobby a puppy” in normal, fast, loud, and slow speech modifications. Articulatory movement traces were recorded using a 3D optical motion capture system. Kinematic measures of average speed (mm/s) and range of movement (mm3) were extracted from the lower lip (± jaw) marker. Two speech language pathologists rated speech clarity for each speaker using a visual analog scale (VAS) approach. Results demonstrated that facial motor capacity increased from early to late stages of recovery. While individuals in the early group exhibited restricted capabilities to adjust their motor system based on the articulatory demands of each speech modification, individuals in the late group demonstrated faster speed and larger-than-normal range of movement for loud speech, and slower speed and larger-than-normal range of movement for slow speech. In addition, subjects in both groups showed overreliance on jaw rather than lip articulatory function across all speech modifications, perhaps as a compensatory strategy to optimize articulatory stability and maximize speech function. Finally, improved speech clarity was associated with loud speech in both stages of recovery.
... Patients presenting with ataxic dysarthria exhibit a scanning pattern of speech, disturbed articulation of both consonants and vowels, and abnormal voice quality [82•], often requiring multiple treatment approaches [83]. The SLP conducts a comprehensive assessment of a patient's respiration, phonation, resonance, articulation, and prosody to properly diagnose ataxic dysarthria [82•] and identifies appropriate treatment goals for each of these areas. ...
Purpose of review
In this review, we present the multidisciplinary approach to the management of the many neurological, medical, social, and emotional issues facing patients with cerebellar ataxia.
Recent findings
Our holistic approach to treatment, developed over the past 25 years in the Massachusetts General Hospital Ataxia Unit, is centered on the compassionate care of the patient and their family, empowering them through engagement, and including the families as partners in the healing process. We present the management of ataxia in adults, beginning with establishing an accurate diagnosis, followed by treatment of the multiple symptoms seen in cerebellar disorders, with a view to maximizing quality of life and effectively living with the consequences of ataxia. We discuss the importance of a multidisciplinary approach to the management of ataxia, including medical and non-medical management and the evidence base that supports these interventions. We address the pharmacological treatment of ataxia, tremor, and other associated movement disorders; ophthalmological symptoms; bowel, bladder, and sexual symptoms; orthostatic hypotension; psychiatric and cognitive symptoms; neuromodulation, including deep brain stimulation; rehabilitation including physical therapy, occupational therapy and speech and language pathology and, as necessary, involving urology, psychiatry, and pain medicine. We discuss the role of palliative care in late-stage disease.
Summary
The management of adults with ataxia is complex and a team-based approach is essential.
The purpose of this analysis was to document intelligibility and naturalness in ataxia, a neurological condition that results from cerebellar damage. The cerebellum is important for normal speech production to scale and coordinate articulatory and laryngeal movements. The disruption of these cerebellar mechanisms has unique implications for how intelligibility and naturalness are affected in ataxia. The results of research on speech in ataxia have important clinical implications for assessment and treatment of individuals with ataxic dysarthria. Speech samples from 27 participants with ataxia and 28 age- and sex-matched control participants were assessed by nine speech-language pathology graduate students for intelligibility and naturalness. Intelligibility was measured as the percentage of words transcribed correctly, and naturalness was assessed as a subjective rating on a seven-point interval scale. Both intra- and inter-rater reliability were moderate to high for both intelligibility and naturalness. Speech intelligibility and naturalness were robustly decreased in the ataxia group compared to the control group; however, the difference was greater for measures of speech naturalness. There were robust relationships among dysarthria severity, length of diagnosis, and speech naturalness in speakers with ataxia, but there were no other robust effects for age, sex, or impact on quality of life for intelligibility or naturalness. Speech naturalness was more impaired than intelligibility in speakers with ataxia. Impaired naturalness can have debilitating consequences for communicative participation, effectiveness, and quality of life. Assessment and treatment for ataxic dysarthria should include aspects of prosodic control for speech naturalness.
The dysarthria of multiple sclerosis is known to worsen as the disease progresses (Darley, Brown and Goldstein 1972). Thus as activities of daily life and opportunities for activity for the person with multiple sclerosis are curtailed by increasing disability, the capacity of their respiratory system is also diminished both by disease and lack of demand on the system (Olgiati, Hofstetter and Bailey 1988). It is a hypothesis of this paper and others that disuse creates a discrepancy between the functional ability that is neurologically available and that which is characteristically used (Olgiati et al., 1988; Olgiati et al.l986). It is this functional overlay that may be the target of speech therapy (Farmakides and Boone 1960). Five subjects with MS and dysarthria affecting intelligibility were involved in a multiple baseline therapy study to establish the efficacy of respiratory exercises in improving functional speech performance. Intervention effects were demonstrated by introducing the therapy to different subjects at successive points in time. Therapy exercises targeted the respiratory system alone with no phonatory or articulatory components. Various measures including laryngographic analysis, clinical motor speech tasks and standardised dysarthria profiles were found to be unsuitable as baseline or repeat measures to show improvement in speech. Intelligibility was chosen as a global and objective repeat measure of functional speech performance and was established for each subject using the Yorkston Beukelman Test of the Intelligibility of Dysarthric Speech. Findings cautiously suggest that certain subjects can benefit from respiratory muscle exercises that improve speech performance as measured by intelligibility. A component of the dysarthria of MS may not be due to neuro-motor dysfunction but to atrophy based on fatigue and disuse of the system. This study suggests that this atrophy may be reversible. The objective measurement of intelligibility and the clinical use of a multiple baseline research format are also discussed.
Introduction:
Children with dysarthria due to cerebral palsy (CP) can experience problems manipulating intensity, fundamental frequency, and duration to signal sentence stress in an utterance. Pauses have been identified as a potential additional cue for stress-marking, which could compensate for this deficit.
Objective:
This study aimed to determine whether children use pauses to signal stress placement, and whether this differs between typically developing children and those with CP.
Methods:
Six children with CP and 8 typically developing children produced utterances with stresses on target words in 2 different positions. Pauses before and after the stressed target words were analyzed in terms of number, location, and duration.
Results:
Both groups inserted pauses into their utterances. However, neither group used pause location or duration in a systematic manner to signal the position of the words stressed.
Conclusions:
The results suggest that pausing was not used strategically by either group to signal sentence stress. Further research is necessary to explore the value of pausing as a cue to stress-marking in general and as a potential compensatory strategy for speakers with dysarthria.
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