Dysphonia Outperforms Voice Change as a Clinical Predictor of Dysphagia.

PURPOSE: Changes in voice quality after consuming food or drink have been used as a clinical indicator of dysphagia during the clinical swallowing evaluation (CSE); however, there is conflicting evidence of its efficacy. This study investigated if dysphonia and/or voice change after swallowing are valid predictors of penetration, aspiration, or pharyngeal residue. Our approach aimed to improve current methodologies by collecting voice samples in the fluoroscopy suite, implementing rater training to improve interrater reliability and utilizing continuous measurement scales, allowing for regression analyses. METHOD: In this prospective study, 30 adults (aged 49-97 years) referred for a videofluoroscopic swallowing study (VFSS) were audio-recorded completing a sustained /i/ prior to VFSS and again after swallowing each bolus during the VFSS. Swallowing function was measured using the reorganized Penetration-Aspiration Scale and the Normalized Residue Ratio Scale. Following listener training, 84 voice samples were perceptually rated using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Ordinal and logistic regression were used to determine whether voice quality and voice quality change after swallowing were predictors of airway invasion and pharyngeal clearance. RESULTS: Results indicated that the presence of dysphonia at baseline during a sustained /i/ task as measured by the CAPE-V predicted airway invasion but not pharyngeal residue. Voice change after swallowing associated with vowel /i/ production as measured by the CAPE-V did not predict either dysphagia measure. CONCLUSION: These results indicate that voice change during a sustained /i/ after swallowing appears unrelated to airway invasion or pharyngeal residue; however, in the absence of known laryngeal pathology, dysphonia prior to a CSE should alert speech-language pathologists of a possible comorbid dysphagia.

The Relationship Between Acoustic and Kinematic Vowel Space Areas With and Without Normalization for Speakers With and Without Dysarthria.

PURPOSE: Few studies have reported on the vowel space area (VSA) in both acoustic and kinematic domains. This study examined acoustic and kinematic VSAs for speakers with and without dysarthria and evaluated effects of normalization on acoustic and kinematic VSAs and the relationship between these measures. METHOD: Vowel data from 12 speakers with and without dysarthria, presenting with a range of speech abilities, were examined. The speakers included four speakers with Parkinson's disease (PD), four speakers with brain injury (BI), and four neurotypical (NT) speakers. Speech acoustic and kinematic data were acquired simultaneously using electromagnetic articulography during a passage reading task. Raw and normalized VSAs calculated from corner vowels /i/, /æ/, /ɑ/, and /u/ were evaluated. Normalization was achieved through z score transformations to the acoustic and kinematic data. The effect of normalization on variability within and across groups was evaluated. Regression analysis was used across speakers to assess the association between acoustic and kinematic VSAs for both raw and normalized data. RESULTS: When evaluating the speakers as three different groups (i.e., PD, BI, and NT), normalization reduced the standard deviations within each group and changed the relative differences in average magnitude between groups. Regression analysis revealed a significant relationship between normalized, but not raw, acoustic and kinematic VSAs, after the exclusion of an outlier speaker. CONCLUSIONS: Normalization reduces the variability across speakers, within groups, and changes average magnitudes affecting speaker group comparisons. Normalization also influences the correlation between acoustic and kinematic measures. Further investigation of the impact of normalization techniques upon acoustic and kinematic measures is warranted. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22669747.

Comparing amplitudes of transcranial direct current stimulation (tDCS) to the sensorimotor cortex during swallowing.

PURPOSE: Transcranial direct current stimulation (tDCS) can alter cortical excitability, making it a useful tool for promoting neuroplasticity in dysphagia rehabilitation. Clinical trials show functional improvements in swallowing following anodal tDCS despite varying dosing parameters and outcomes. The aim of the current study was to determine the most effective amplitude criterion (e.g., 0 mA [sham/control], 1 mA, 2 mA) of anodal tDCS for upregulating the swallowing sensorimotor cortex. METHOD: As a novel paradigm, tDCS, functional near-infrared spectroscopy (fNIRS), and surface electromyography (sEMG) were simultaneously administered while participants completed a swallowing task. This allowed for measurement of the cortical hemodynamic response and submental muscle contraction before, during, and after tDCS. At the conclusion of the study, participants were asked to rate their level of discomfort associated with tDCS using a visual analog scale. RESULTS: There was no significant difference in the hemodynamic response by time or amplitude. However, post-hoc analyses indicated that in the post-stimulation period, changes to the hemodynamic response in the left (stimulated) hemisphere were significantly different for the groups receiving 1 mA and 2 mA of tDCS compared to baseline. Participants receiving 1 mA of tDCS demonstrated reduced hemodynamic response. There was no significant difference in submental muscle contraction during or after tDCS regardless of amplitude. Anodal tDCS was well tolerated in healthy adults with no difference among participant discomfort scores across tDCS amplitude. CONCLUSIONS: During a swallowing task, healthy volunteers receiving 1 mA of anodal tDCS demonstrated a suppressed hemodynamic response during and after stimulation whereas those receiving 2 mA of anodal tDCS had an increase in the hemodynamic response. tDCS remains a promising tool in dysphagia rehabilitation, but dosing parameters require further clarification.

Vowel reduction across tasks for male speakers of American English.

This study examined acoustic variation of vowels within speakers across speech tasks. The overarching goal of the study was to understand within-speaker variation as one index of the range of normal speech motor behavior for American English vowels. Ten male speakers of American English performed four speech tasks including citation form sentence reading with a clear-speech style (clear-speech), citation form sentence reading (citation), passage reading (reading), and conversational speech (conversation). Eight monophthong vowels in a variety of consonant contexts were studied. Clear-speech was operationally defined as the reference point for describing variation. Acoustic measures associated with the conventions of vowel targets were obtained and examined. These included temporal midpoint formant frequencies for the first three formants (F1, F2, and F3) and the derived Euclidean distances in the F1-F2 and F2-F3 planes. Results indicated that reduction toward the center of the F1-F2 and F2-F3 planes increased in magnitude across the tasks in the order of clear-speech, citation, reading, and conversation. The cross-task variation was comparable for all speakers despite fine-grained individual differences. The characteristics of systematic within-speaker acoustic variation across tasks have potential implications for the understanding of the mechanisms of speech motor control and motor speech disorders.

Acoustic variation during passage reading for speakers with dysarthria and healthy controls.

PURPOSE: Acoustic variation in a passage read by speakers with dysarthria and healthy speakers was examined. METHOD: 15 speakers with Multiple Sclerosis (MS), 12 speakers with Parkinson's disease (PD), and 14 healthy speakers were studied. Acoustic variables included measures of global speech timing (e.g., articulation rate, pause characteristics), vocal intensity (e.g., mean sound pressure level and intensity modulation), and segmental articulation (i.e., utterance-level second formant interquartile range (F2 IQR)). Acoustic measures were obtained from three segments operationally defined to represent the beginning, middle, and end of a reading passage. Two speaking conditions associated with common treatment techniques for dysarthria were included for comparison to a habitual speaking condition. These conditions included a slower-than-habitual rate (Slow) and greater-than-habitual intensity (Loud). RESULTS: There was some degree of acoustic variation across the three operationally-defined segments of the reading passage. The Slow, Loud and Habitual conditions yielded comparable characteristics of variation. Patterns of acoustic variation across the three passage segments also were largely similar across speaker groups. CONCLUSIONS: Within-task acoustic variation during passage reading should be considered when making decisions regarding speech sampling in clinical practice and research. The contributions of speech disorder severity and linguistic variables to within-task acoustic change warrant further investigation. LEARNING OUTCOMES: Readers will be able to (1) discuss the motivation for studying and understanding within-task variation in contextual speech, (2) describe patterns of acoustic variation for speakers with dysarthria and healthy speakers during passage reading, (3) discuss the relationship between non-habitual speaking conditions and within-task variation, (4) understand the need to consider within-speaker, within-task variation in speech sampling.

Acoustic and perceptual correlates of faster-than-habitual speech produced by speakers with Parkinson's disease and multiple sclerosis.

UNLABELLED: Acoustic-perceptual characteristics of a faster-than-habitual rate (Fast condition) were examined for speakers with Parkinson's disease (PD) and multiple sclerosis (MS). Judgments of intelligibility for sentences produced at a habitual rate (Habitual condition) and at a faster-than-habitual rate (Fast condition) by 46 speakers with PD or MS as well as a group of 32 healthy speakers revealed that the Fast condition was, on average, associated with decreased intelligibility. However, some speakers' intelligibility did not decline. To further understand the acoustic characteristics of varied intelligibility in the Fast condition for speakers with dysarthria, a subgroup of speakers with PD or MS whose intelligibility did not decline in the Fast condition (no decline group, n=8) and a subgroup of speakers with significantly declined intelligibility (decline group, n=8) were compared. Acoustic measures of global speech timing, suprasegmental characteristics, and utterance-level segmental characteristics for vocalics were examined for the two subgroups. Results suggest acoustic contributions to intelligibility under rate modulation are complex. Potential clinical relevance and implications for the acoustic bases of intelligibility are discussed. LEARNING OUTCOMES: Readers will be able to (1) discuss existing evidence for the use of rate change to facilitate intelligibility, (2) describe acoustic-perceptual characteristics of a faster-than-habitual rate among speakers with mild dysarthria, (3) discuss the relationships between rate, intelligibility, suprasegmental variables, and segmental variables, (4) identify the need to further investigate the acoustic basis for intelligibility and its potential theoretical and clinical implications.

Formant transitions in varied utterance positions.

AIM: Acoustic characteristics associated with varied utterance positions were examined to understand the acoustic consequences of potential articulatory changes near utterance boundaries. METHODS: Second formant transition characteristics, including transition duration (ms), transition extent (Hz), and derived slope of transition (Hz/ms), of 12 healthy speakers of American English were examined for two diphthong transitions in sew and sigh and one consonant-vowel transition in bee in utterance-initial, utterance-final, and utterance-end positions. Speakers performed a task of contrastive stress variation that served to demonstrate the changeability of acoustic characteristics as an index of articulatory change in shaping the vocal tract. RESULTS: Contrastive stress, as compared to words spoken without increased stress, was associated with longer transition duration, greater transition extent, and a decreased slope. Although some utterance position effects were present, no systematic differences consistent with boundary strengthening or declination were found. CONCLUSION: Findings suggest that varied utterance positions may be associated with stimulus-dependent variation in articulatory changes that is reflected in the acoustic output. These results indicate the need to further understand the construct of utterance-level speech materials, such as carrier phrases, in clinical practice and research.

Acoustic and perceptual consequences of clear and loud speech.

OBJECTIVE: Several issues concerning F2 slope in dysarthria were addressed by obtaining speech acoustic measures and judgments of intelligibility for sentences produced in Habitual, Clear and Loud conditions by speakers with Parkinson's disease (PD) and healthy controls. PATIENTS AND METHODS: Acoustic measures of average and maximum F2 slope for diphthongs, duration and intensity were obtained. Listeners judged intelligibility using a visual analog scale. Differences in measures among groups and conditions as well as relationships among measures were examined. RESULTS: Average and maximum F2 slope metrics were strongly correlated, but only average F2 slope consistently differed among groups and conditions, with shallower slopes for the PD group and steeper slopes for Clear speech versus Habitual and Loud. Clear and Loud speech were also characterized by lengthened durations, increased intensity and improved intelligibility versus Habitual. F2 slope and intensity were unrelated, and F2 slope was a significant predictor of intelligibility. CONCLUSION: Average diphthong F2 slope was more sensitive than maximum F2 slope to articulatory mechanism involvement in mild dysarthria in PD. F2 slope holds promise as an objective measure of treatment-related changes in the articulatory mechanism for therapeutic techniques that focus on articulation.

Effect of level of presentation to listeners on scaled speech intelligibility of speakers with dysarthria.

OBJECTIVE: This study examined the effect of intensity level of presentation on scaling of speech intelligibility in speakers with and without dysarthria. PATIENTS AND METHODS: A total of 50 utterances produced by speakers with dysarthria and healthy speakers were played to 60 listeners in four conditions, which consisted of two different presentation levels ('high' vs. 'low') and equalization of levels across utterances ('adjusted' vs. 'unadjusted'). Speech intelligibility was scaled by using a direct magnitude estimation technique with and without modulus. RESULTS: A significant decrease in speech intelligibility was indicated when the stimuli were adjusted to have fixed intensity on the most intense vocalic nuclei of each word, while no significant change was found between 'high' and 'low' presentation level conditions. CONCLUSION: The findings suggest that an increase in presentation level alone does not result in significant improvement in speech intelligibility ratings. The results are discussed by considering clinical implications in conducting speech therapy with emphasis on intensity variation.

Augmentation of zone II flexor tendon repair using growth differentiation factor 5 in a rabbit model.

PURPOSE: Modulation of zone II flexor tendon repair healing using growth factors may reduce the incidence of complications, such as rupture and fibrosis. We hypothesized that sutures coated with growth differentiation factor 5 (GDF5) will stimulate the healing of zone II flexor tendon repairs. METHODS: We created and immediately repaired zone II flexor tendon lacerations in the second and fourth toe of the right forepaw of 44 New Zealand White rabbits. One tendon was repaired with suture coated with GDF5, whereas the other tendon was repaired with suture without GDF5 (control). We randomized the allocation of GDF5 and control suture to either toe. A proximal tenotomy of the flexor digitorum profundus at the level of the wrist was performed to relieve tension on the more distal repairs. Rabbits were euthanized at 21 or 42 days after repair. Four rabbits (8 tendons) underwent histological analysis at each time point; the remaining repairs were tested biomechanically in a blinded fashion. RESULTS: Control tendons demonstrated distinct borders at the transection site and less endogenous repair at 3 weeks. The Soslowsky histological score for collagen was better in the GDF5 group at both time points (p≤.003). All tendons failed at the repair site. The maximum load was significantly greater (p=.04) in the GDF5 group (11.6 ± 3.5 N) compared with control tendons (8.6 ± 3.0 N) at 3 weeks. The maximum load was not significantly different (p=.12) at 6 weeks. We observed no significant differences in stiffness at either time point (p>.11). CONCLUSIONS: The results demonstrate that GDF5 has an early beneficial effect on tendon healing in zone II flexor tendon repairs in a rabbit flexor tendon injury model.

Scapholunate instability: current concepts in diagnosis and management.

Injuries to the scapholunate joint are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction, lost time from work, and interference with activities. The complex arrangement and kinematics of the 2 rows of carpal bones allows for an enormous degree of physiologic motion, and a hierarchy of primary and secondary ligaments serves to balance an inherently unstable structure. Although insufficient to cause abnormal carpal posture or collapse on static radiographs, an isolated injury to the scapholunate interosseous ligament may be the harbinger of a relentless progression to abnormal joint mechanics, cartilage wear, and degenerative change. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics. In this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate articulation and provide a foundation for understanding the spectrum of scapholunate ligament instability. We propose an algorithm for treatment based on the stage of injury, degree of secondary ligamentous damage, and arthritic change.

The effects of walking speed on obstacle crossing in healthy young and healthy older adults.

The effects of walking speed and age on the peak external moments generated about the joints of the trailing limb during stance just prior to stepping over an obstacle and on the kinematics of the trailing limb when crossing the obstacle were investigated in 10 healthy young adults (YA) and 10 healthy older adults (OA). The peak hip and knee adduction moments in OA were 21-43% greater than those in YA (p

Explaining the de-prioritization of primary prevention: physicians' perceptions of their role in the delivery of primary care.

BACKGROUND: While physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery. METHODS: A focus group with regional primary care physician (PCP) Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine) participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology. RESULTS: The PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care. CONCLUSIONS: The secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration.

Physician perceptions of primary prevention: qualitative base for the conceptual shaping of a practice intervention tool.

BACKGROUND: A practice intervention must have its basis in an understanding of the physician and practice to secure its benefit and relevancy. We used a formative process to characterize primary care physician attitudes, needs, and practice obstacles regarding primary prevention. The characterization will provide the conceptual framework for the development of a practice tool to facilitate routine delivery of primary preventive care. METHODS: A focus group of primary care physician Opinion Leaders was audio-taped, transcribed, and qualitatively analyzed to identify emergent themes that described physicians' perceptions of prevention in daily practice. RESULTS: The conceptual worth of primary prevention, including behavioral counseling, was high, but its practice was significantly countered by the predominant clinical emphasis on and rewards for secondary care. In addition, lack of health behavior training, perceived low self-efficacy, and patient resistance to change were key deterrents to primary prevention delivery. Also, the preventive focus in primary care is not on cancer, but on predominant chronic nonmalignant conditions. CONCLUSIONS: The success of the future practice tool will be largely dependent on its ability to "fit" primary prevention into the clinical culture of diagnoses and treatment sustained by physicians, patients, and payers. The tool's message output must be formatted to facilitate physician delivery of patient-tailored behavioral counseling in an accurate, confident, and efficacious manner. Also, the tool's health behavior messages should be behavior-specific, not disease-specific, to draw on shared risk behaviors of numerous diseases and increase the likelihood of perceived salience and utility of the tool in primary care.