Making the Unintelligible Intelligible in     

Motor Speech Disorders
Session 1787
November 19, 2010
American Speech‐Language‐Hearing Association Convention

Jessica Huber Purdue University
Christopher Dromey Brigham Young University
Antje Mefferd Wichita State University
Monica McHenry University of Houston
Rupal Patel Northeastern University
Kathryn Yorkston University of Washington
Respiratory Therapy to Improve
Intelligibility
Jessica E. Huber, Ph.D.
Purdue University
jhuber@purdue.edu
Impact of Respiration on Intelligibility
y Many impairments result in weak respiratory support:
y Traumatic brain injury, Parkinson’s disease, spinal cord injury,
Cerebral Palsy, Amyotrophic Lateral Sclerosis, Multiple
Sclerosis
y Weak respiratory muscles or reduced breath support cause
y Short utterances
y Pausing at locations unrelated to syntax
y Lack of pauses without inspiration (for emphasis)
y Typical speakers use a range of utterance lengths and
tend to pause at syntactically important locations
 Importance of Pausing
y Listeners use pauses to parse running speech into
syntactic units
y Lack of pauses for emphasis (non-breath pauses)
means more breath pauses
y Longer pauses (associated with breathing) can be
disruptive at minor syntactic boundaries
y Breath pauses occurring at locations unrelated to
syntax makes speech less intelligible
y Both can be particularly important when coupled
with a degraded speech signal

Grosjean & Collins, 1979; Hammen & Yorkston, 1994; Shah et al., 2006; Winkworth et al., 1994, 1995
Importance of Utterance Length
y If all utterances are short, speech will sound
more uniform and less natural
y Short utterances increase the likelihood of breath
pauses occurring at locations unrelated to syntax
y Short utterances reduce the number of non-
breath pauses
y Short utterances impact the speaker’s turn
maintenance
Example Passage for Breath Pausing
Assessment
Papa [MIN] was a great man. [MAJ]Working all his life [MIN] as a
carpenter, [MIN] he built homes [MIN] for other people. [MAJ] Papa
[MIN] was an excellent craftsman. [MAJ] Anyone who worked with Papa
[MIN] knew that he was an honest man. [MAJ] Papa [MIN] gave himself
to his work, [MIN] toiling daily [MIN] for small amounts of money.
[MAJ] No one [MIN] disliked Papa. [MAJ] In fact, [MIN] neighbors
[MIN] used to bring Papa apples [MIN], pears [MIN], and other fruits
[MIN], especially around the holidays. [MAJ]
I remember Papa [MIN] for his kind ways. [MAJ]What I remember
[MIN] was the manner [MIN] in which Papa dressed, [MIN] the way he
carried himself. [MAJ] Papa [MIN] was such a strong man. [MAJ]
Devoted to his family [MIN], especially his children [MIN], Papa [MIN]
worked night and day [MIN] to provide for us. [MAJ] Although we never
showed Papa our appreciation [MIN] on a daily basis [MIN], I know that
he felt our love [MAJ], or so I hope.
Example
Devoted to his family, especially his children
[MIN], Papa worked night and day to
provide for us. [MAJ] Although we never
showed Papa our appreciation [MIN] on a
daily basis, I know that [UNR] he felt our
love, or so [UNR] I hope.
How to Assess Utterance Length
y Breath group: all of the words said on one breath
y Have a patient read a paragraph and watch for
breaths
y Count the number of syllables/breath group
y Record the patient reading the paragraph into
acoustic software
y Measure the duration (in seconds) of each breath
group
y Calculate speech rate (number of syllables/duration)
 Utterance Length and Speech Rate
14.5 5.4
14
5.2
13.5

Syllables/Second
Number of Syllables

13 5

12.5 4.8
12 4.6
11.5
4.4
11
1 2 4.2
Data Collection Period 1 2
Data Collection Period
OC PD n=8 in each group OC PD

Huber, Darling, and Francis (2009)

 How to Assess Pausing
y Count the number of pauses without inspiration (for emphasis)
y Determine the syntactic nature of breath pause locations
y Breath pauses could be marked while the patient talks, watching
the chest wall
y If the sample is recorded to acoustic software, can examine all
pauses (breath and non-breath)
y A good rule of thumb is to look for pauses longer than 125-250 ms
y The longer the pause, the more likely that it is a breath pauses (usually at
least 350 ms long)
y Sometimes can see a noisy signature in the spectrogram showing that a
breath was taken
Example of Measuring a Breath Pause
 Breath Pausing
12
80
% Total Breaths at Major Boundaries

% Total Breaths at Boundaries

70 10

Unrelated to Syntax
60
8
50
6
40
30 4
20
2
10
0 0
Time 1 Time 2 Time 1 Time 2

Control Participants PD n=8 in each group Control Participants PD

Darling, Huber, and Francis (2009)

 Treatment – Strength
y If the respiratory muscles are too weak to
produce adequate subglottal pressure (Ps) for
speech, can use non-speech, blowing activities
until speech is possible
y However, these are unlikely to improve a person’s
ability to generate Ps during speech once the muscles
are strong enough
y Can also use inspiratory and expiratory muscle
trainers
Inspiratory and Expiratory Muscle
Trainers
y Individual breathes into a
tube with nose clips on
y On the end of the tube or
mask is a resistance
y Resistance makes it
www.aspireproducts.org
difficult to breathe in or
out
 Inspiratory and Expiratory Muscle
Trainers
y Help with breath support for weak respiratory muscles
y Has been shown to be effective in individuals with
Parkinson’s disease or spinal cord injury
y Do not use with patients who get fatigued easily (ALS,
Myasthenia Gravis) or with those who problems do not
involve muscle weakness
y Generally need an MD script for use
y Do not use the trainers instead of speech therapy, continue
to work on speech. During therapy, you check progress

Pitts, Bolster, Rosenbek, et al. (2009); Silverman, Sapienza, Saleem, et al. (2006)
 Basic Muscle Training Guidelines
y Train at about 75% of the patient’s maximum expiratory or
inspiratory pressure
y Increase the amount of resistance as the individual becomes stronger
(maintain overload)
y Specificity of training:
y Train with the task you are trying to improve
y Muscle trainers do this to a point (especially in expiratory muscle
training)
y You are training with a downstream resistance and speech is breathing with a
downstream resistance (larynx and articulators)
y Frequency:
y Must train regularly – 5 sets of 5 breaths (25 breaths total) 5 days per
week for 4 weeks
y Use with individuals who can train outside of therapy

Pitts, Bolster, Rosenbek, et al. (2009); Silverman, Sapienza, Saleem, et al. (2006)
Treatment – Strength

y Can use sound pressure level as gross feedback

about subglottal pressure
y Have patient speak louder, target a specific SPL,
or talk in noise
y Work up a hierarchy:
y Sustained phonation
y Syllables
y Words
y Utterances, increasing in length
Treatment – Posture
y This is a common treatment for individuals with Cerebral Palsy or
Parkinson’s disease
y When necessary, work with OT and PT to position the person so
hypertonicity or rigidity does not interfere with speech
y Encourage to sit up straight so rib cage expansion is less limited
y If inspiratory muscles are ok, but expiratory muscles are weak, can
have individual speak while lying down
y Gravity assists with expiration, but works against inspiration
y Is a good test to determine if a patient’s respiratory support is
affected by weak abdominal muscles
y However, individual will want to sit up to speak, so must address
communicative needs
 Compensation for Respiratory Support
y Paddles: board which individual can lean into when
speaking
y Clients who need it usually do not have the truncal
stability and movement control to use them
y Binder: used with individuals with abdominal muscle
weakness or paralysis
y Elastic corset-like band, placed around the abdomen,
below the last rib
y Make sure it does not encompass the rib cage
y Individual will not wear the binder to sleep or eat
y Should get a MD script to use a binder with a patient
Compensation– Binder
y Supports the abdominal wall – performing some of
the functions of the abdominal muscles during
speech
y A good quick test for whether a binder will work is
if the individual’s speech improves laying down
y Disadvantage: It will make it harder for the
diaphragm to contract since the abdominal contents
can not be displaced outward as easily
y Do not use if individual has inspiratory weakness

Watson & Hixon (2001)

Treatment – Respiratory Pausing
y Mark reading passages with breath pausing to teach them
how to break a passage up at syntactic boundaries and how to
gauge a preparatory inhalation
y Progress to them marking the passage, to producing short
passages without marks, to answering short questions (first
by preparing the answer and determining where to breathe
then spontaneously)
y Once they are doing better:
y Teach them to pause for emphasis
y Work on speech naturalness

Bellaire,Yorkston, and Beukelman (1986)

 SpeechVive™
y Portable device designed to
improve communication in patients
with PD
y Plays babble noise in one ear when
the person talks through a non-
occlusive ear fitting
y Uses the Lombard Effect to elicit
louder and clearer speech
spontaneously
y Normal day-to-day settings become
a training situation to improve
speech and communication
Utterance Length, Rate, and
SpeechVive™
7.4 4.75

Speech Rate (syllables per second)

4.7
7.2
4.65
Number of Syllables

4.6
7
4.55
6.8 4.5
4.45
6.6
4.4
4.35
6.4
4.3
6.2 4.25
Off On Off On Off On Off On

Pre Pre Post Post Pre Pre Post Post

Session and Condition Session and Condition
n=6 n=6

Work in Progress for Grant: R01 DC009409, Huber, Stathopoulos, and Sussman
Breath Pausing and SpeechVive™
Pre Off Post Off

Breath Breath
15.3 Pauses 18 Pauses
37.6 Non-Breath 38.8 Non-Breath
Pauses Pauses

Pre On Post On

Breath Breath
11 11
Pauses Pauses
Non-Breath Non-Breath
40 41.6
Pauses Pauses

n=5

Work in Progress for Grant: R01 DC009409, Huber, Stathopoulos, and Sussman
Adaptability
y Make sure to work on how speaker adapts to
different speech tasks:
y Short vs. long utterances
y Speaking to one listener vs. a group
y Speaking in quiet vs. in noise
Normative Data: Utterance Length
y Huber (2008) – Figure 3 shows the number of syllables per
breath group for four different utterance length groupings
during extemporaneous speech (comfortable and loud) in
young and older adults
y Hoit & Hixon (1987) – Tables 7 and 10 list number of
syllables per breath group for reading and extemporaneous
speech in young, middle-aged, and older men
y Hoit et al. (1989) – Tables 6 and 9 list number of syllables
per breath group for reading and extemporaneous speech in
young, middle-aged, and older women
Normative Data: Speech Rate
y Huber (2007) – Figure 2 shows speech rate (syllables per
second) in reading and extemporaneous speech (comfortable
and loud) in young adults
y Huber (2008) – Figure 3 shows speech rate for four different
utterance length groupings during extemporaneous speech
(comfortable and loud) in young and older adults
y Sadagopan & Huber (2007) – Table 3 lists speech rate in
reading for older adults and individuals with Parkinson’s
disease
Phonation and 
Intelligibility
Christopher Dromey
Brigham Young University
voice source
• generates most acoustic energy for speech
• nearly periodic fundamental
• harmonics influence quality
• dysphonia can affect ease of speaking

• but does voice really affect intelligibility?
source‐filter theory
• larynx output = vocal tract input
• what we hear is a combination
• laryngeal source features
• vocal tract filtering influence

• disordered source impacts final result
• plain yogurt – what if it’s bad?
• “garbage in, garbage out”
but are there other explanations?
• can bad voicing do more than contaminate the 
source?
source‐filter connectedness
• speech is highly coordinated
• voiced/voiceless distinctions
• precise timing of articulators and larynx
• natural linkages: larynx/vocal tract
• can source disorders affect articulation?
• will a stumbling larynx pull articulation down 
with it?
lip‐larynx link 1: spasmodic dysphonia
pre‐injection
4

2 upper lip
Displacement (mm)

-2

-4

-6
post‐injection
-8
0 200 400 600 800 1000
lower lip
1200 1400 1600

0
1

Displacement (mm)
-2
0.5 continuous  -4
Correlation

0
correlation -6

-0.5
-8
0 100 200 300 400 500 600 700 800 900
-1
0 200 400 600 800 1000 1200 1400 1600

0.5
Correlation

-0.5

-1
0 100 200 300 400 500 600 700 800 900
lip‐larynx link 2: Parkinson disease
• LSVT targets the voice ‐ intensively
• inadvertent impact on other speech parameters
• we are treating more than the vocal folds
• larger articulator movements
• faster articulator movements
• improved articulatory precision
• without any clinical focus on articulation
lip‐larynx link 3: muscle tension 
dysphonia
• tight larynx – often severe dysphonia
• SLP intervention can be effective
• reduce hyolaryngeal tension
• does this loosen tongue and jaw muscles?

• formant slopes steeper after treatment
• reading sample duration shorter – more fluent
• pauses decreased in number and length
benefits of improved voice
• source/filter interdependence
• better voice linked to better speech
• functional intelligibility gains from voice 
treatment

• take home: include laryngeal function in treating 
dysarthria
thank you!
Articulation
Antje S. Mefferd, PhD SLP-CCC
Wichita State University
 Articulatory Segmental Clarity/
Movements Acoustics Intelligibility

Commonly, it is assumed that the quality of

articulatory behaviors will be apparent in the speech
acoustic signal and potentially have an impact on
speech intelligibility.

However, empirical data showing a strong association between
articulation and acoustics is lacking for impaired speech.
2

Saturation Effects

Formants remain unaffected during alteration of
vocal tract configurations


Quantal Effect (Stevens, 1972; 1989).

Acoustic insensitivity to tongue body positions

Allows for a certain degree of articulatory inaccuracy
without negative effects on the acoustic signal

3
High

High Intelligibility
Phonetic Specification

Ideal

Typical

Low Intelligibility

Dysarthric
(e.g., Darley et al, 1969; Turner, Tjaden & Weismer, 1995)
(e.g., Hartelius et al., 2001; McHenry, 2003)
Low
Low Phonetic Variability High
ARTICULATION ACOUSTICS
THE EXTENT OF TONGUE DISPLACEMENT THE EUCLIDIAN DISTANCE IN F1/F2 SPACE

SLOW

FAST

5
 Kinematics Acoustics

STI = 6.67 STI = 5.43

points points

steps steps

Articulatory Variability

Commonly calculated using the spatiotemporal index (STI) (Smith et al., 1995).

Acoustic Variability

Currently, it has been measured only at discrete points (Turner, Tjaden, &
Weismer, 1995).

6
Modifications of
speaking rate and
loudness elicit natural
variations in the
specification and
variability of articulatory
movements and speech
acoustics.

Slow Speech
e.g., Tasko & McClean, 2004,
Kleinow et al., 2001

Loud Speech
e.g., Dromey & Ramig, 1998;
Schulman, 1989,
Huber & Chandrasekanan, 2006,
Kleinow et al., 2001

Fast Speech
e.g., Goozee et al., 2000,
Kleinow, et al., 2001
7

Results yield implications about current treatment
approaches for speakers with dysarthria.
 Speaking rate reductions
 Loud speech (LSVT)

8

3-D Electromagnetic
Articulography
(Medizintechnik Carstens, Germany)

3 sensors placed on
midsagittal tongue,
only posterior tongue
sensor used for analysis

3 sensors on the head
(mounted on goggles)

9
Tip of the tongue
movement during
syllable production
“tatata”

10

10 healthy speakers (5 male, 5 female)

“Tomorrow Mia may buy you toys again”

Typical

Fast

Loud

Slow
 Articulation

Slow speech All other comparisons p< .01

18

 Highest degree of articulatory 16 p< .05

Lingual Displacement (mm)

14 p< .05
and acoustic specification 12
10
among all speaking conditions 8

Loud speech 6
4
2
 Significantly more specified 0

than typical speech in the Fast Typical

Speech Task
Loud Slow

kinematic domain. Significantly

Acoustics
more specified in the acoustic 1600 **p< .01 All other comparisons were non-significant
domain if controlled for gender. 1400

Vowel Space Size (Hz)

Task effects are larger for 1200

1000 **
**

slow speech than for loud 800

600
**

speech in both domains. 400

200

0
Fast Typical Loud Slow
Speech Task

12
Mefferd, A.S. & Green, J.R. (2010). Articulatory–to-Acoustic Relations in Response to Speaking Rate and Loudness change. JSLHR 53, 1206-1219.

Strong positive linear relationship
2500

Male Takers
females
males
r(99) = .86, p < .01
(Acoustic Distance in Hz)

2000
Acoustic Specification

Female Talkers
1500

r(99) = .83, p < .01

The degree of articulatory
1000
specification is preserved in the
500 acoustic domain.

0
0 5 10 15 20 25
Articulatory Specification
(Lingual Displacement in mm)

13

Goal: Maximize articulatory specification

But how?

Presumably, slow speech allows for more time to reach the
articulatory target.

May not always be the case

Slow speech did not elicit systematic change in vowel
space in talkers with ALS (Turner, Tjaden, Weismer, 1995)

Increase in vowel space during loud speech (Sapir et al., 2007,
Tjaden & Wilding, 2004, Wenke, Petrea & Theodoros, 2010)

More research is needed to study the effects of rate and loudness
change on articulation, speech acoustics and intelligibility.
 Articulation Acoustics
10 other comparisons were non-significant all comparisons were non-significant
10
9 **p< .01
9
8
8
Kinematic STI value

Acoustic STI value

7
7
6 6
**
5 5
4 4
3 3
2 2
1 1
0 0
Loud Fast Slow Typical Slow Typical Loud Fast
Speech Task Speech Task

Loud speech was significantly less variable compared to slow speech;

t(9) = -3.5, p< .01.
This is consistent with previous findings (Kleinow et al., 2001)

15

No significant
15 females linear relationship
Acoustic Variability (Acoustic STI)

males

r(38) = .05, p = .76

10

This is consistent
with Quantal
5
Theory (Stevens, 1989)
 An insensitivity of
0 speech acoustics to
0 5 10 15
Articulatory Variability (Kinematic STI) articulatory
changes
16

Raises the possibility that articulatory variability
does not have a direct impact on speech intelligibility

The degree of variability in the kinematic domain is not preserved in the
acoustic domain

However, articulatory variability due to motor speech
impairments may contribute more to speech
intelligibility decrements.

Impaired speakers are typically more variable

Need to test articulatory-to-acoustic relations in talkers
with dysarthria!

17
 11/21/2010

Adequate tissue is present, but not adequately

innervated

Classically associated with flaccid dysarthria

Monica McHenry, Ph.D., CCC-SLP

University of Houston
.

Loss of energy in acoustic spectrum is similar to loss of

Isit impacting intelligibility?

energy in breathiness

Will remediation of hypernasality
improve intelligibility?

What is the impact of
hypernasality on the client?

1
 11/21/2010

In cases of increased hypernasality, breathiness

decreased the perception of hypernasality

In cases of decreased hypernasality, breathiness
increased the perception of hypernasality

Hypernasality
Surgical

Nasal air emission

Behavioral

Prosthetic

Decreased intelligibility, primarily due to weak
pressure consonants
• Short breath groups
• Reduced loudness

Increased vocal effort

CPAP
McHenry, M. A. & Liss, J. (2006). The impact of
stimulated vocal loudness on nasalance in dysarthria.

Increased recruitment across physiological systems

Study based on 28 individuals with TBI

Effect depends on dysarthria type

2
 11/21/2010

Dysarthria dB – to Nasalance – Dysarthria dB – to loud Nasalance

Type loud to loud Type –
mild flaccid 5% ↑ 0 to loud
sev. spastic 19% ↑ 16% ↓
mod. flaccid 4% ↑ 45% ↓ mild spastic 6% ↑ 42% ↑
mild flaccid 6% ↑ 16% ↓ sev. spastic 9% ↑ 25% ↑
mod. flaccid 7% ↑ 4% ↓ sev. spastic 10% ↑ 40% ↑
mod. flaccid 17% ↑ 13% ↓ sev. spastic 2% ↑ 2% ↓
mod. spastic 3% ↑ 4% ↑
mod. flaccid 14% ↑ 0
sev. spastic 1% ↑ 11% ↓
mild flaccid 11% ↑ 24% ↓ mod. spastic 3% ↑ 12% ↓
mild flaccid 8% ↑ 42% ↓ sev. spastic 4% ↑ 0
mild flaccid 14% ↑ 18% ↓ sev. spastic 7% ↑ 18% ↑
sev. spastic 3% ↑ 16% ↑

LSVT
Explore effect of vocal effort both

5 individuals with hypernasality increased and decreased
associated with chronic stable dysarthria
Ideally with instrumentation

3/5 reduced perceived nasality
immediately post tx

2/3 reduced nasalance

Only 1/5 maintained changes at 6 month
follow-up

Developed by David Keuhn, University
Palatal lift

of Illinois, Champagne-Urbana ◦ Long-standing history

Limited data available
Nasal obturator

Attempted with individual with 32% ◦ More recent
nasalance

No change after two months

3


The most important part of the process
11/21/2010

Props up soft palate

Provides mechanical impedance to air
attempting to enter the nasal cavity

From Evidence based Practice Guidelines
for Dysarthria: Management of
velopharyngeal function

Academy of Neurogenic Communication
Disorders and Sciences
4
 11/21/2010

Better – flaccid
Better – adequate or recovering

Poorer – spastic
Poorer – Poor
◦ Tightness tends to make lift harder to ◦ Some modifications of lift can facilitate
retain articulation, such as a dropped palate to
decrease distance from tongue to
alveolar ridge and palate.

Better – yes
Better – yes

Poorer – no
Poorer – no
◦ Though desensitization procedures have ◦ Presence of lift typically stimulates
been reported increased saliva production
◦ Presence of lift can make swallowing
more difficult

Better – adequate
Better – Pressure consonants much less

Poorer – Poor because of inability to seal oral cavity
◦ Difficult to keep track of appliance
Poorer – No or minimal difference

◦ Need external cues in place to monitor between them

use
◦ Need to establish habits such as where
to keep lift when not in use (such as
when sleeping)

5
 11/21/2010

Karnell et al., 2004

19 patients – varied etiologies
Mean nasalance life out – 37.5

8 with neurogenic disorder
Lift in – 17.1

3 with head injury
Statistically significant difference

With lift, adequate oral/nasal resonance

6
 11/21/2010

Nasal Obturator – Mark Hakel –Madonna

Hospital

7
  Stress, rhythm and intonation patterns
  Functions & roles: linguistic and affective
  Acoustic cues: F0 (pitch), intensity (loudness),
duration (length)
  Prosodic cues often serve multiple functions
simultaneously
  Characterize type and degree of impairment/
residual ability
  Determine the need for & focus of treatment

  Differential diagnosis btw AOS and DYS

 yet, there little agreement on the stimuli, methods

and dimensions of prosody assessment in MSD
  Pitch: level, variation, ease & appropriateness of
modulation
  Loudness: level, variation, ease & appropriateness of
modulation
  Rate: in read and spontaneous speech
  Phrasing: at syntactically appropriate junctures,
frequency, length of breath groups
  Stress: cues used, aligned with appropriate words,
contrast strength
Direct physiological measurements: changes in each speech subsystem
during speech production - across various tasks and stimuli
Acoustic measurements: changes in F0, intensity and duration during
various speech tasks
Perceptual measures: judge pitch and loudness level & variation and
rate on likert-type scales
  Ludlow & Bassich (1983) – used a 13 point scale (7 =
normal, 1 = extreme low, 13 = extreme high)
  Chenery, Murdoch et al. – measure severity of dysfunction
on scale of 1-4; pitch on scale of 1-7
 Also need to assess perceptual categories within a given speaker
  Words with varying stress patterns
  Noun-verb distinctions: CONduct vs. conDUCT

  Sentences with contrastive prosody

  My blue car? vs. My blue car.
  That MAN ran fast vs. That man RAN fast
  Chocolate cookies and milk vs. Chocolate, cookies, and
milk

  Discourse dynamics
  Turn taking
  Conveying contrastive meanings
  Choosing 1/+ treatment strategy
  Knowing what to introduce when
  Selecting stimuli
  Selecting tasks
  Knowing how to assess/measure change
  Prosody is not the icing on the cake it is the
scaffolding
  Embed prosody in the earliest stimuli/tasks
  Choose functional stimuli
  Choose meaningful, communicative contexts
as tasks
Shape what they can control
  If speakers can vary duration  help them exploit this
to convey contrasts
  Listeners attune to consistencies not cues (Howell, 1993;
Peppe et al 2000)

Optimize success via any & all modalities

  Facial expressions convey prosody (Massaro et al, 2008)
  Gestures convey prosody (Shattuck-Hufnagel et al, 2004; Sargin et
al, 2008)
  Choose stimuli that address both segmental and
prosodic goals
  Choose stimuli with appropriate complexity
  Length
  Syntax
  Semantic content
  Functional carryover

  Embed stimuli in communicative tasks/scenarios

  Use techniques that were initially developed for a
different purpose
  Barrier games
  Map task

  Strategies used in language intervention may be

used to elicit prosody
  Assessments used in children can be modified for
adults
  PEPS-C: Profiling Elements of Prosodic Systems – child
(Peppe et al. 2006)
(Allen & Arndorfer, 2000)
Do you like amusement parks? Well, I sure do. To amuse myself, I
went twice last spring. My most MEMORABLE moment was riding
on the Caterpillar, which is a gigantic rollercoaster high above the
ground. When I saw how high the Caterpillar rose into the bright
blue sky I knew it was for me. After waiting in line for thirty minutes,
I made it to the front where the man measured my height to see if I
was tall enough. I gave the man my coins, asked for change, and
jumped on the cart. Tick, tick, tick, the Caterpillar climbed slowly up
the tracks. It went SO high I could see the lake nearby. Boy was I
SCARED! I thought to myself, “There’s no turning back now.” People
were so scared they screamed as we swiftly zoomed fast, fast, and
faster along the tracks. As quickly as it started, the Caterpillar came
to a stop. Unfortunately, it was time to pack the car and drive home.
That night I dreamt of the wild ride on the Caterpillar. Taking a trip to
the amusement park and riding on the Caterpillar was my MOST
memorable moment ever!

(Patel et al)
  Adapt tried and tested strategies (rate
reduction, LSVT) to incorporate prosodic
modulation
  Global strategies may not be effective for
improving naturalness
  strategies that emulate how healthy talkers
compensate in adverse speaking conditions can be
highly effective
  Acoustically – in prosody and intelligibility
  Personal satisfaction
  Listener Effort
  Behavioral and/or Social variables
  Do it often to change course if needed
1. Get functional early on
2. Exploit Residual abilities
3. Design dual purpose stimuli
4. Recycle & repurpose tasks
5. Modify & refine strategies
6. Measure change often
Intelligibility and Participation
Kathryn Yorkston, Ph.D.
Professor
Rehabilitation Medicine
 Health Condition
ICF Framework

Body Activity Participation

Participation
Activity
Functions
Impairment Restriction
Limitation

Restrictions in 
Changes in structure  Limitations in 
e.g. respiration for  Changes in speech  involvement in life 
& function  execution of tasks
speech  intelligibility situations

Environmental Personal 
Factors Factors
 Speech
Impairment
Intelligibility of 
Acoustic Signal
Supplemented
Speaker Naturalness
Intelligibility
Compensations
Signal
Independent Communicative
Information Effectiveness 

Preferred Communicative
Participation
Roles

Physical & Social
Yorkston et al, 2010 Listener Environment
 Intervention Targets
• Interviewed 44 adults with communication disorders
• SD, MS, PD, CVA, ALS & others
• Asked about interference with communicative
participation.
Dysarthric Speech

Preferred Communicative
Participation
Roles

Physical & Social
Listener Environment
 Intervention Targets
Did things differently:
- Vigilance
- Scripts & Rehearsal
- Follow-up to gauge Dysarthric Speech
understanding
- Use other modes

Preferred Communicative
Participation
Roles

Physical & Social
Listener Environment
 Intervention Targets
Types of Listeners
- Don’t know: Doesn’t matter
- Know but doesn’t matter
Dysarthric Speech
- Know & they need to know

Preferred Communicative
Participation
Roles

Physical & Social
Listener Environment
 Intervention Targets
What listeners need to know
- Be patient
- Don’t read my emotions in
Dysarthric Speech
my speech
- To guess or not to guess

Preferred Communicative
Participation
Roles

Physical & Social
Listener Environment
 Intervention Targets
Difficult roles
- Groups
- Phone
Dysarthric Speech

Preferred Communicative
Participation
Roles

Physical & Social
Listener Environment
 Intervention Targets
Environmental noise is critical across
diagnoses

Dysarthric Speech

Preferred Communicative
Participation
Roles

Physical & Social
Listener Environment
 Health Condition
ICF Framework

Body Activity Participation

Participation
Speech 
Functions
Impairment Restriction
Intelligibility

Environmental Personal 
Factors Factors
 References
• Baylor, C., Burns, T. M., Eadie, T., Britton, D., & 
Yorkston, K. (submitted). Participation across 
disorders: A qualitative study of interference with 
communicative participation across communication 
disorders in adults. 
• World Health Organization. (2001). International 
Classification of Functioning, Disability and Health 
(ICF). Geneva, Switzerland: Author.
• Yorkston, K., Beukelman, D., Strand, E., & Hakel, M. 
(2010). Management of motor speech disorders in 
children and adults (3rd ed.). Austin, TX: Pro‐Ed.