, r / 7 ,lj (5/0 ABSTRACT SPECTROGRAPHIC, PAUSIMETRIC, AND INTELLIGIBILITY MEASURES IN PARKINSON'S DISEASE BY Dennis C. Tanner The purpose of this study was to analyze acoustically and perceptually the speech of Parkinson subjects who were receiving anti-parkinson medication. The subjects used in this study consisted of 12 patients, 6 male and 6 female, diagnosed by physicians as having Parkinson's disease or parkinsonism. Each sex category was further subdivided into 3 subjects with severe symptoms and 3 subjects with mild symptoms. A group of 12 age and sex matched individuals was used as a control. The following questions were formulated to define this research: 1. Is there a difference between Parkinson and normal subjects' duration of articulatory pauses, using the opera- tional definition of a pause and the method of measurement introduced by Tosi (1965)? 2. Is there a significant difference in the Euclidian distances between the mean frequency of the first and second Dennis C. Tanner formants of vowels uttered by Parkinson subjects and the same vowel uttered by normal subjects? 3. Do the Parkinson subjects differ significantly in intelligibility from normals as measured by the Multiple Choice Intelligibility Test by Black (1963)? 4. How do untrained judges perceive the speech of Parkinson subjects, in particular: A. How do untrained judges perceive isolated vowel-bracketed plosives produced by Parkinson subjects? B. Is there a difference between Parkinson sub- jects' and control subjects' production of isolated vowel-bracketed plosives as determined by untrained judges? The distribution of articulatory pauses from the Rainbow Passage for both the Parkinson group and the control group were compared statistically for differences in mean duration of the pauses. The results of the statistical analysis indi- cated the control subjects' mean duration of articulatory pauses to be longer than the mean duration of the articula- tory pauses for the Parkinson subjects. Spectrograms of the cluster and CNC samples were obtained to determine the mean frequencies of the first and second formants of the following vowels for both the Parkin- son group and the age-matched controls: /I/, /e/, /ae/, /a/, /A/, /)/, /o/. Euclidian distances from the control sub— jects' mean frequencies and the Parkinson's subjects' mean Dennis C. Tanner frequencies were tested statistically for significance. The statistical analysis indicated no significant differences among subjects of each subgroup but significant differences among Parkinson and normals of corresponding subgroups were observed. Although no interaction was observed across the various subgroups, there was some homogeneflarbetween vowel- sex-formant number-type of diagnosis with the amount and direction of the Parkinson groups'frequency deviations. Data on intelligibility of the Parkinson subjects was obtained by using the Black Test of Intelligibility and was compared with the normalized data provided with the test. The results of the intelligibility analysis suggest that Parkinson subjects diagnosed by their physicians as possess- ing either mild or severe involvement, will have reduced intelligibility corresponding to the severity of the disease. The results also suggest that women with a severe diagnosis have better intelligibility than men with the same condition, and vice versa for subjects with a mild diagnosis. The perceptual features regarding plosive production were judged by a panel of untrained judges. The results indicated that judges perceive the isolated vowel-bracketed plosives as, in decending order of occurrence, a) other non- tested plosives, b) fricatives, c) nasals, and d) glides. However, the plosive analysis also indicated that the Parkin- son groups'production of isolated plosives were as intelli- gible as an age-matched control group. The major conclusions Dennis C. Tanner regarding the plosiweanalysis are that 1) the Parkinson subjects'difficulty in the production of plosives reported in the literature is only true relative to ongoing speech,and/or 2) the widespread use of anti-parkinson medication has improved the overall populations' production of plosives to the extent that they no longer differ from age-matched normals. SPECTROGRAPHIC, PAUSIMETRIC, AND INTELLIGIBILITY MEASURES IN PARKINSON'S DISEASE BY Dennis C. Tanner A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Audiology and Speech Sciences 1976 ACKNOWLEDGMENTS The author wishes to give grateful acknowledgment to his friend and advisor, Dr. Oscar Tosi. Special thanks are extended to Connie Supal and Bill Culbertson for their assistance with the raw data. Sincere thanks are also extended to staff and patients of the Burcham Hills Retirement Community and the Eaton County Medical Care Facility. Finally, this dissertation is dedicated to my wife, Jody, for her assistance, support, and understanding. ii TABLE LIST OF TABLES . . . . LIST OF FIGURES . . . LIST OF APPENDICES . . CHAPTER I. INTRODUCTION . OF CONTENTS Purpose of the Study . Definition of Terms Organization of the Report II. REVIEW OF THE LITERATURE Epidemiology Physical Symptomatology Classification Psychological Factors . Language Disorders Auditory Deficits . The "Acceleration" and I! On -Of Medication-—Effects on Speech Parkinsonian Dysarthria . Effects On Oral Mobility Effects On Respiration Effects On Phonation . Acoustic Aspects Of Dysarthric Speech Durational Qualities . Summary . . . III. Section I: Subjects . Apparatus . Speech Samples SUBJECTS, EQUIPMENT, MATERIALS, AND iii General Procedure f" Phenomena PROCEDURES Page vi vii 01.5w 0" \l 12 13 16 18 21 23 26 29 31 34 35 36 39 40 40 41 42 CHAPTER Page Section II: Pause Analysis . . . . . . . . . 43 Section III: Spectrographic Analysis . . . . 51 Section IV: Intelligibility Analysis . . . . 53 Section V (A & B): Plosive Analysis . . . . 55 IV. RESULTS AND DISCUSSION . . . . . . . . . . . . 58 Pause Analysis . . . . . . . . . . . . . . . 59 Spectrographic Analysis . . . . . . . . . . . 64 Intelligibility Analysis . . . . . . . . . . 67 Plosive Analysis . . . . . . . . . . . . . . 68 V. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . . . 78 Summary . . . . . . . . . . . . . . . . . . . 78 Conclusions . . . . . . . . . . . . . . . . . 81 Recommendations . . . . . . . . . . . . . . . 82 REFERENCES . . . . . . . . . . . . . . . . . . . . . . 84 APPENDICES . . . . . . . . . . . . . . . . . . . . . . 93 iv 10. ll. 12. LIST OF TABLES Neuromuscular defects in dysarthrias . . . . . . Parkinson and control subjects by age, sex, and severity of involvement . . . . . . . . . . . Mean and standard deviation of articulatory pauses extracted from the Parkinson group . . Mean and standard deviation of articulatory pauses extracted from the control group . . . Analysis of variance of pause duration for Parkinson subjects . . . . . . . . . . . . . . Average mean frequencies of lst and 2nd formants . . . . . . . . . . . . . . . . . . . Intelligibility of Parkinson subjects in percent . . . . . . . . . . . . . . . . . . . Number and percent of errors perceived as voiced plosives, unvoiced plosives, fricatives, glides, laterals, and nasals by eight judges for all Parkinson subjects . . Number and percent of errors perceived as voiced plosives, unvoiced plosives, fricatives, glides, laterals, and nasals by eight judges for severe Parkinson subjects . . . . . . . . . . . . . . . . . . . Number and percent of errors perceived as voiced plosives, unvoiced plosives, fricatives, glides, laterals, and nasals by eight judges for mild Parkinson subjects . . . . . . . . . . . . . . . . . . . Total correct for Parkinson subjects and control subjects . . . . . . . . . . . . . . . Data summary across classification . . . . . . . V Page 25 41 60 61 62 65 67 69 71 72 74 75 LIST OF FIGURES Figure Page 1. Time-Amplitude plot of speech waves before and after rectification . . . . . . . . . . . 44 2. "Intrawave gaps" within complex sound waves: Intervals of relative low levels of pressure within a wave . . . . . . . . . . . . 46 3. Block diagram of the Pausimeter and associated instruments . . . . . . . . . . . . 48 4. Voice Identification Inc. Sound Spectrograph Series 700 . . . . . . . . . . . . . . . . . . 52 5. Sound spectrogram of the words "joke" and "gap" . . . . . . . . . . . . . . . . . . . . 54 vi LIST OF APPENDICES Appendix A. The Rainbow Passage . . . . . . . . . . . . B. The Multiple Choice Test of Intelligibility by Black . . . . . . . . . . . . . . . . C. The Cluster List . . . . . . . . . . . . . D. The CNC List . . . . . . . . . . . . . . . E. The Vowel-Bracketed Plosives . . . . . . . F. Parkinson Subjects CNC List . . . . . . . . G. Control Subjects CNC List . . . . . . . . . H. Parkinson Subjects Cluster List . . . . . . I. Control Subjects Cluster List . . . . . . . J. Plosive Analysis, Open Response Subtest Form A . . . . . . . . . . . . . . . . . K. Plosive Analysis, Closed Response Form B O O O O O O O O O I O O O O O O 0 vii Page 93 95 96 97 98 99 100 101 102 103 104 CHAPTER I INTRODUCTION Parkinson's disease, a disorder of the extra— pyramidal system, is one of the major chronic disabilities of adulthood which creates a need for residential nursing care. The progression of the syndrome may range over twenty or more years. The disorder is characterized by muscular rigidity, tremor at rest, and impairment of voluntary move- ments. The speech of individuals with Parkinson's disease is often greatly disturbed and may include deviation in the normal processes of respiration, phonation, resonance, proso- dy, and articulation. Cramer (1940), Nielson (1941), Merritt (1955), and Hoberman (1958) were some of the early authors to examine the verbal symptoms associated with the disease. Most of these early studies described perceptual features and were often limited by the lack of precise methodology and instru- mentation. Within the last fifteen years, the research into the verbal manifestations of Parkinson's disease has become more precise and abundant. Canter's (1963, 1965a, 1965b) three part analysis of Parkinson speech was the first comprehen- sive analysis of the respiratory, articulatory, and phonatory characteristics of the disease. Canter observed imprecise production of plosive consonants and discoordination of phonatory and articulatory activity to be the main contri- butors to defective articulation. Meldolesi (1954), Brombart (1961), Leanderson et a1. (1972), Logemann et a1. (1973), and Darley et al. (1975) have also observed lingual andilabial mobility deficits to be associated with the disease. Schilling (1925), Nugent et a1. (1958), De La Torre et a1. (1960), Ewanowski (1964), and Kim (1968) are generally in agreement that decreased maximum breathing capacity and faster respiratory rates are symptomatic of Parkinson's disease. The phonatory characteristics in Parkinson's disease have been studied by Neilson (1941), Merritt (1955), Grewel (1957), Darley et al. (1969b), and Darley et a1. (1975). Many of these studies report contradictory results and are thoroughly discussed in Chapter II. The research is limited regarding certain acoustic aspects of Parkinson's disease. Lehiste (1965) included a Parkinson speaker in her spectrographic analysis of dysarth- ria. Canter (1963) defined a pause as "stOppage of speech" and referred to them in determination of the durational qualities of the syllable. In addition to the fact that there is little research available specifically addressing the acoustic aspects of Parkinson's disease, most of the previous research was completed before the widespread use of anti-parkinson medica— tion. The use of levodOpa (L—Dopa) and other anti-parkin- son medication has, in effect, altered the "typical" clinical symptoms reported in early research. Nakano et a1. (1973) report significant increase in overall speech intelligibility and improved labial movements with levodopa therapy. Yahr and associates (1968), Lee et a1. (1971), Stern et a1. (1972), Hunter et a1. (1973), and others report mild to dramatic benefits from levodopa therapy. Today, most patients with Parkinson's disease receive varying dosages of anti-parkinson medication. Purpose of the Study The purpose of the present study was to analyze acoustically and perceptually the speech of Parkinson subjects who are receiving anti-parkinson medication. The following questions were formulated to define this research: 1. Is there a difference between Parkinson and normal subjects' duration of articulatory pauses, using the opera- tional definition of a pause and the method of measurement introduced by Tosi (1965)? 2. Is there a significant difference in the Euclidian distances between the mean frequency of the first and second formants of vowels uttered by Parkinson subjects and the same vowel uttered by normal subjects? 3. Do the Parkinson subjects differ significantly in intelligibility from normals as measured by the Multiple Choice Intelligibility Test by Black (1963)? 4. How do untrained judges perceive the speech of Parkinson subjects, in particular: A. How do untrained judges perceive isolated vowel-bracketed plosives produced by Parkinson subjects? B. Is there a difference between Parkinson sub- jests' and control subjects' production of isolated vowel-bracketed plosives as determined by untrained judges? Definition of Terms Definitions of major terms employed in this study are as follows: Articulatory pause. As defined by Tosi (1965), arti- culatory pauses are ". . . flow of acoustic energy of which the relative amplitudes remain below a predetermined value of a parameter called 'pause maximum amplitude, Lp,’ provided the duration of such levels of amplitude is more than a pre- determined amount of time, indicated by another parameter called 'pause-minimum duration, Tp.' The parameter Lp is expressed as a percentage or dB ratio with respect to the average peak amplitudes (pressure or voltage) of the recti- fied waves of the sample of sound analyzed. The parameter Tp is expressed in milliseconds" (p. 134). Formant. Wood's (1971) definition of a formant is used in this study to designate a natural mode of resonance in the vocal tract characterized on a spectrogram by a dark area indicating a relatively high intensity of a group of frequency components in a vowel. Intelligibility. In this study, intelligibility is defined as the capacity to be understood or comprehended; that which is measured by the Multiple Choice Test of Intelligibility by Black (1963). Plosive. "Any speech sound made by creating air pressure flithe vocal tract and suddenly releasing it" (Wood, 1971, p. 18). In this study, the plosives were "vowel-bracketed" or produced between the articulation of two identical vowels. The samples are isolated in the sense that the vowel-bracketed plosives were not taken from ongoing speech samples. Parkinson's disease. In this study, Parkinson's disease is used synonymously with parkinsonism and paralysis agitans. The subjects in this study were labeled as having Parkinson's disease if their physician indicated Parkinson's disease, parkinsonism, or paralysis agitans upon diagnosis and had prescribed anti-parkinson medication. Organization of the Report Chapter I has introduced some of the deficits in the research dealing with the verbal symptomatology in Parkinson%5 disease. The studies reported in the introduction are more thoroughly discussed in the literature review. Also, in the introduction, the terms pertinent to this study were listed and defined. Chapter II consists of a review of the literature including studies that relate to epidemiology, physical symptomatology, classification, and psychological factors associated with the disease. The available studies that relate to respiration, phonation, resonance, prosody, and articulation are also reported. Chapter III discusses the selection of the subjects, equipment used in the study, and the procedure used to obtain thegdata. Chapter IV contains a presentation of the results of the statistical analyses. Appropriate charts and tables are presented to clarify the results. Chapter V includes a summary of the study and conclu- sions which can be drawn from the results. Recommendations for future research are also presented. The Appendices contain the raw data utilized in the analyses. CHAPTER II REVIEW OF THE LITERATURE Epidemiology In 1817, James Parkinson published the "Essay on the Shaking Palsy" (Parkinson, 1817). The disease is now referred to by his name, "Parkinson's disease" or "parkinsonism." Epidemiological studies are generally in agreement regarding the prevalence of the disorder. Pollock and Hornabrook (1966) report the prevalence of parkinsonism in Wellington, New Zealand,to be 106 per 100,000 population. Jenkins (1966) found a prevalence of 85/100,000 in the Australian state of Victoria. Brewis et a1. (1966) found an overall rate of 112.5/100,000 in a survey of the city of Carlisle, England. A survey of patients seen at the Kenyatta National Hospital, Nairobi, during 1965, indicates that 75 patients were admitted for neurological diseases; two with parkinsonism (Ojiambo, 1966). Hamdi (1966) reviewed 24 cases of parkinsonism admitted to the Neurological Unit of the Republic Teaching Hospital in Baghdad, Iraq, in the years 1958, 1959, and 1960 and recorded a 1.1 percent occurrence of parkinsonism from the patients studied during those years. Hsueh and Jeang (1966) reported 1.5 percent occurrence of parkinsonism of patients 60 years and older in a large general hospital in Taiwan. In the United States, Blumenthal (1965) reviewed the patient records of a Veterans Administration psychiatric hospital and reported that of 2,265 patients, those with "paralysis agitans" constituted 1.6 percent of the patients with neurological diseases and 0.2 percent of the total patient population. Hussar (1966) reviewed the autopsy protocols of 1,276 white male schizophrenic patients who died at age 40 or over during 1954-59 in Veterans Administration hospitals and reported that a clinical diagnosis of paralysis agitans had been made in 12 or about 1 percent. Autopsy confirmed eight of the original diagnoses. In a survey of the utilization of institutional facilities in Kansas, Lewis (1965) found that 268 (2.1 percent) of 12,869 admissions to adult care homes were for Parkinson's disease. Lewis also concluded that about 0.1 percent of patients hospitalized in short-term general hospitals were given the diagnosis of Parkinson's disease at discharge. Goodman (1953) proposes that parkinsonism is one of the major chronic disabilities of adulthood creating a need for residential nursing. DeJong (1958) estimated the prevalence of the syndrome in the United States to be between 1,000,000 and 1,500,000. The U.S. Department of Health, Education, and Welfare (1968) suggests thatthe prevalence of parkinsonism is generally uniform among widely scattered geographical regions and in different racial groups. H.E.W. concludes that, "Patients with parkinsonism comprise between 1 to 2 percent of patients with neurological disease" (p. 3). Physical Symptomatology In the incipient stage of the development of the dis- order, the patient may have a gradual slowing down of activi- ties. Early symptoms include diminishing of normal recipro- cal movements, slight changes in facial expression, some loss of dexterity, and some difficulty in performing small coordinate movements such as shaving, dressing, manipulating buttons, and writing (Eliasberg, 1959). The first symptom may be a slight trembling of the thumb or monotone voice characteristics (Von Werssowetz, 1964). Rigid muscles, often seen in Parkinson's disease, are usually equal in degree in all opposing muscle groups, although frequently unequal in intensity on opposite sides of the body and rotary movements of the trunk are markedly diminished (Von Werssowetz, 1964). The body and its segments often assume a general attitude of flexion (Wachs and Boshes, 1961). The rigidity often causes loss of automatic un- conscious movements. Blinking of the eyelids and changes of facial expression may be affected early. Facial muscle rigidity produces an expressionless face. Von Werssowetz (1964) attributes the typical "mask—like" face of Parkinson's disease to contribute to speech difficulties. Rigidity often causes akathisia (restlessness) of the extremities (Hodge, 1959). Tremor is another significant symptom in parkinsonism. The tremor is generally rhythmic, slow, and occurring at a rate of three to six movements per second, and alternating 10 between Opposing muscle groups. Tremor of the tongue and jaw may be present (Von Werssowetz, 1964). Dyskinesia (loss of skill) in the upper limbs is common in the disorder and slowness of voluntary movements is often present although muscle power is usually adequate (Oliver, 1967). Oculogyric crisis may be present in certain types of parkinsonism. During the crisis the eyes will often turn up forcefully and is commonly seen in the post-encephalitic type but seldom occurs in the idiOpathic disease (Von Werssowetz, 1964). Occasionally, patients with Parkinson's disease experience a "Parkinson's crisis" as a result of psychological trauma or sudden withdrawal of anti-parkinson drugs. The Parkinson's crisis is a sudden severe exacerba- tion of tremor, rigidity, and dyskinesia accompanied by acute anxiety, sweating, tachycardia, and hyperpnoea and may be accompanied by oculogyric crisis (Oliver, 1967). Many of the other symptoms of the disorder are probable combina- tions of tremor, rigidity, or dyskinesia. Von Werssowetz (1964) reports that many of the major signs of parkinsonism usually disappear during sleep. Chusid (191” reports that disturbed metabolism of brain amines may possibly be the basis for the development of parkinsonism. "Abnormally low concentrations of dopamine, norepinephrine, and serotonin in the basal ganglia and hypo- thalamus and their abnormal excretion in the urine have been reported, suggesting a defect in normal binding of amines" (p. 334). Von Werssowetz (1964) states that any dysfunction 11 of the extrapyramidal system can cause parkinsonism. It is, however, difficult to define exactly what the extrapyramidal system includes. Generally it is accepted that all motor mechanisms of the central nervous system, excluding those of the pyramidal tract are "non-pyramidal" or extrapyramidal motor systems (Jung and Hassler, 1960). Kreig (1953) defines the extrapyramidal system to include the extra- pyramidal area of the cerebral cortex of each hemisphere, the thalamic nucleus, corpus striatum including caudate nucleus, putamen, pallidum, sub thalamus, and the rubrul and reticular systems. These structures are all loosely connected by numerous tracts which create a functional rather than an anatomic system. It is believed that the extra- pyramidal system causes facilitation of impulses which pass from higher centers to the lower motor neuron cells of the agonist muscles, while at the same time suppressing the activity of the antagonist muscles (Asai and Schaltenbrand, 1960). Von Werssowetz~(l964) lists the functions of the extrapyramidal systems: 1) integration and facilitation of primary movements of skeletal muscles, 2) integration of associated and ancillary movement patterns, and 3) control and inhibition of postural reflexes. Chusid (1973) states that the "extrapyramidal system may be regarded as a functional system with 3 layers of integration: cortical, striate (basal ganglia), and tegmental (midbrain). The bulboreticular inhibitory and facilitatory area receives fibers from cerebral cortical 12 areas, the striatum, and the anterior cerebellum. The principal functions of the extrapyramidal system are con- cerned with associated movements, postural adjustments, and autonomic integration. Lesions at any level may obscure or abolish voluntary movements and replace them with involun- tary movements" (p. 16). Classification Since James Parkinson's essay was published, many scientists and clinicians have classified the disorder. Von Werssowetz (1964) separates Parkinson's disease from the parkinsonian syndrome. Parkinson's disease is divided into idiopathic and arteriosclerotic categories and parkin- sonian syndrome includes post infectious, toxic or metabolic, drug induced, and miscellaneous. According to Von Werssowetz (1964» Parkinson's disease differs from the parkinsonian syndrome by the absence of cortical involvement, lethargy, oculogyric abnormalities, and slowing and enfeeblement of emotional responses and behavioral disturbances. Generally, however, studies do not separate Parkinson's disease from parkinsonism. Oliver (1967) provides the following classi- fication system: IdiOpathic Postencephalitic Atherosclerotic Drug induced Carbon monoxide poisoning Chronic manganese poisoning Chronic mercury poisoning Midbrain compression Traumatic l3 Controversy still exists regarding the pathologic dif- ferences among the various clinical forms of the disease. To compound the classification difficulties, no conclusive evi- dence exists that lesions of a specific structural component in the extrapyramidal tract are responsible for a specific symptom in the classification category. It is, however, gen- erally accepted that there are characteristic differences between clinical forms of Parkinson's disease. Generally, it is believed that in the post-encephalitic form the sub- stantia nigra is significantly affected (Spatz, 1925; Wolf, 1954). The globus pallidus, putamen, and the caudate nucleus are affected in the idiopathic type (Lhermitte, 1921; Keschner and Sloane, 1931; Vogt and Vogt, 1920). In the arteriosclero- tic form of the disease, the most severely affected are the globus pallidus, striatum, and external capsule (Davidson, 1952; Denny-Brown, 1946). In many forms of the disease the cortex reveals significant changes (Benda, 1952; Davidson, 1942) and in certain instances the damage is particularly severe in the temporal lobes. Generally, in Parkinson's dis- ease, the substantia nigra is considered as the site where pathologic alterations are most important, regardless of the suspected etiology (Greenfield, 1958; Baker and Nelson, 1959). Psychological Factors Studies describing the psychological, emotional, or mental status of patients with parkinsonism are contradic- tory. Some studies report widespread intellectual 14 impairment: others show focal brain damage. Emotional con- striction and rigidity with impaired perceptual flexibility are often reported. Other studies report little or no emo- tional or intellectual deficits (H.E.W., 1968). In Parkinson patients without severe motor deficits, Levita et a1. (1964) found a decrease in verbal functions and impairment of arousal of attention and the maintenance of set. They were unable to relate cognitive deficits to the patient's age, voluntary movement impairment, or the lateral- ity of sub-cortical involvement. As the disease increased in severity, they found consistent intellectual, cognitive, and perceptual losses. Nadvornik (1962) suggests that as the disease advances there is increased depression, organ fixation, and somatic preoccupation. Ffienfgeld (1965) found the following psychological reactions in a study of 129 patients with the disease: 1) depression, 14.7 percent: 2) depression plus emotional lability or emotional inflexi- bility, 34.1 percent; 3) depression, emotional lability, and decreased spontaneity, 25.6 percent; 4) the above psycholo- gical abnormalities, plus disabling loss of interest and decreased vitality and will, 15.5 percent: 5) similar personality abnormalities with memory impairment and de- creased judgment, decreased perception, concentration, insight and judgment, 10.1 percent. Hartman-Von Monakow (1965) relates the mental status to the type of parkinsonism. The postencephalitic patients 15 demonstrate restlessness, irritability, and loss of inhibi- tion especially when the disease develops early in life. When developed late in life, the postencephalitic parkinson- ism patient is frequently characterized as having decreased initiative and spontaneity, slow psychic functioning, and decreased drive. Arteriosclerotic parkinsonism is often associated with disturbances of orientation, comprehension, memory, concentration, and affect as well as the same psychol- ogical changes reported in the postencephalitic parkinsonism. Drugs and surgery also are reported to affect the psy- chological functioning in parkinsonism. H.E.W. (1968) reports, "Large doses of Dopa as amphetamine and related drugs can be expected to result in increased psychomotor activity which may be manifested by choreiform and athetotic activity, agitation, confusion, hallucination, and gross delirium" (p. 14). Hartman-Von Monakow (1972) found post- operative (stereotaxic surgery of the thalamus) psychologi- cal problems especially permanent psycho-organic symptoms and transient somnolence, hallucinations, and disorientation. Hoehn and Yahr (1969) studied a group of patients with parkinsonism and found about 25 percent had difficulty with speech, balance, and mental function after a unilateral thalamic lesion (172 cases), and further difficulty with these symptoms appeared after the contralateral lesion in 50 to 75 percent of the cases (43 cases). H.E.W. (1968) concludes that much of the psych010gical reactions seen in 16 parkinsonism are a mixture of disease, age, and drug effect. Language Disorders Studies differ regarding the extent of language deficits in unoperated parkinsonian patients. Although unoperated parkinsonism is generally associated with sub- cortical involvement (Levita, et al. 1964), specific language disturbances have been reported. Myers (1967) noted language disturbances with lesions of the thalamus. Ojemann and Ward (1971) have hypothesized that short-term verbal memory and verbal functions may be attributed to the dominant ventrolateral thalamus. Penfield and Roberts (1969) conclude, "The functions of all three cortical speech areas in man are coordinated by projections of each to parts of the thalamus and the elaboration of speech is somehow carried out by means of these circuits"(pp. 207-208). Levita and Riklan (1970) caution, however, that presence of neurological involvement is not necessarily associated with distinct verbal-cognitive changes in unOperated parkinsonism. Reitan and Boll (1971) report verbal, cognitive, and intel- lectual losses associated with the disease. Levita and Riklan (1973) conclude that the discrepancies in many studies may reflect differences in sampling. Language deficits following surgery for relief of tremor and rigidity in Parkinson's disease have been widely reported in the literature (Cooper et a1., 1968; Cooper, 1961: Mundinger and Riechert, 1963). Riklan and Levita 17 (1970) report the presence of language deficits, especially word-finding and alterations in articulation, in patients receiving subcortical surgery. Levita and Riklan (1973), using several scales of linguistic performance, conclude: 1) verbal-cognitive functions do not vary as a function of anterior-posterior, medial-lateral, or depth parameters of surgical lesion placement; 2) verbal-cognitive changes are not significantly or differentially related to lesion size or site within the confines of the ventrolateral nucleus of the thalamus. Almgren et a1. (1969) report that parkinsonian patients treated with a left-sided lesion as compared with a right-sided lesion, showed a more impaired postoperative performance on the Stroop Color-Word Test and a memory test for word pairs. In another study, Almgren et a1. (1972) suggest that the differences in verbally expressed cognition between subjects with left-sided and right-sided ventro- lateral thalamotomy extend well beyond the immediate post- Operative period. Levita and Riklan (1973) report deficits in verbal functions decrease in degree or can no longer be observed within six months after surgery. Samra et a1. (1969) examined 27 deceased parkinsonian patients who had undergone thalamic surgery and correlated premorbid language skills with the surgical lesions in each case. The following conclusions were drawn: 1. A lesion strictly confined to the ventrolateral ' nucleus of the thalamus may be followed by language and/or speech deficits. 18 2. No definite relationship existed between post- operative language or speech deficits and partial involvement of thalamic nuclei surrounding the ventrolateral nucleus; H fields of Forel; subthalamic nucleus or red nucleus. Also, mild encroachment on the internal capsule could be tolerated without language or speech deficits, as long as the pyramidal tract remained intact. 3. The size of the lesion was not related to post- operative language and/or speech deficits. 4. Postoperative language deficits were mild and improved in time; whereas speech disturbances could be either mild, moderate, or severe. 5. When language deficits did occur, they followed surgery on the left dominant hemisphere in most instances. In contradistinction, no definite relationship was found between the side of surgery and speech deficits. 6. Language and speech disturbances are most frequent- ly associated with bilateral rather than unilateral surgery, regardless of the cerebral hemisphere involved in the second operation (p. 510). Auditory Deficits The existence of auditory disturbances in post- encephalitic parkinsonian patients has been reported by Barontini and Cannizaro (1956). They found consistent audiometric results which suggest that patients suffering from this form of Parkinson's disease have hypoacusia of the "receptive type.“ Other studies suggest middle ear pathologies (Torrini, 1956) and inner ear disorders (Ferreri, 1931) as reasons for the apparent loss in hearing acuity. There is also evidence that perceptual disorders may be associated with lesions in the basal ganglia (Mettler, 1955). 19 Jerger et a1. (1960), using a battery of auditory tests, provided a comprehensive evaluation of the hearing deficits associated with parkinsonism. The study of 16 patients with the disease concluded that involvement of the central auditory pathways exists in some patients. No appreciable difference between experimental and control groups were observed on routine audiometric measures such as the pure-tone and conventional discrimination tests. However, on more difficult auditory tasks, a deficit closely related to the clinical types of the disease was observed. Idiopathic patients did not perform as well as the controls in this study. The "Acceleration" and "On-Off" Phenomena Canter (1963) reports the speech qualities of some patients with Parkinson's disease to be characterized by a slow rate of articulatory positioning. Conversely, Darley et al. (1969b) refers to occasional "short rushes of Speech" in parkinsonian dysarthria. Occasional occurrences of rapid speech has also been reported by Grewel (1967), Laszewski (1956), and West et al. (1957). This speed-up of the arti- culatory movements is referred to as the acceleration pheno- menon. The paradox that exists, in this aspect of the speech of parkinsonian patients, is how a patient can have such disparate symptoms as rigidity and reduced range of movements in one instance and uncontrolled acceleration behavior in another. 20 Netsell et a1. (1975) offer the hypothesis that "undershooting" is the basis for the perception of accel- erated speech in some cases of parkinsonism. According to the authors, "The speaker might excite the rigid muscula- ture with normally timed neural control signals for voluntary movements (neuromuscular control signals) only to have the speech articulators fail to reach the necessary position for production of a particular speech sound before beginning the movement for the following sound" (p. 170). This failure to reach the intended position is the basis for the acceleration phenomenon. The authors also report that one subject could gain control of the acceleration behavior by speaking louder. The "on-off" phenomenon (akinesia paradoxica), which is a rapid spontaneous fluctuation of symptoms and signs of parkinsonism, has long been recognized as a characteristic feature of the disorder (Claveria et a1. 1973). Transient attacks of dysphonia have been noted and attributed to the phenomenon. Since the introduction of levodopa, the phenomenon has been reported with increasing frequency (Yahr, 1972; Demasio et a1. 1973; Markham, 1972). When they occur, the attacks accompanying L-Dopa therapy are reported to be more profound and prolonged. Damasio et a1. (1973) report the phenomenon to occur in approximately 10 percent of the cases. Barbeau (1972) suggests that the "on-off" attacks represent levodopa toxicity and suggests upper dose 21 limits. Claveria et al. (l973),in a study that related plasma levodopa levels to confusion, facial hypokinesia, and dysphonia also concluded that the phenomena is related to excessive plasma concentrations of levodopa. Medication--Effects on Speech Many clinical reports are in agreement regarding the immediate effects of levodopa therapy in Parkinson's disease. Hunter et a1. (1973) report that two-thirds of the patients gain modest to spectacular benefits from L-DOpa therapy. Other reports indicate that sustained response and in many cases arrest of the disease can occur during prolonged administration of the drug (Lee et a1. 1971; Stern et al. 1972). ‘Reports of general speech changes associated with L—Dopa therapy have been reported. Berkmayer and Hornykie- wicz (1961) observed improvement in speech and other symptoms during treatment with L-Dopa. Yahr and associates (1968) report that the immediate speech changes associated with L-DOpa therapy are not as dramatic as the improvement in other physical symptoms. Hunter et a1. (1973), in a study of 187 parkinsonian patients, report that after two years of L-DOpa therapy, parkinsonian disabilities continued to increase despite retention of partial responsive- ness to levodopa. The same study also reported that while most benefited after 3 month's treatment, after 36 months only 40 percent of the patients remaining in the study 22 maintained their initial improvement. One of the interesting facts to emerge was that by 24 months into the study, indi- vidual scores for tremor, rigidity, and posture were largely maintained although initial improvement of speech and sialorrhea (excessive secretion of saliva) had been largely lost. The authors also note that the clinical patterns of deterioration varied considerably from one patient to another. Nakano et a1. (1973), in a double-blind investigation, studied speech intelligibility (Black test) and labial movements in relation to the effects of procyclidine hydro- chloride (Kemadrin), levodopa, a placebo (lactose), and no drug therapy. A significant increase in overall speech intelligibility with L-Dopa was reported. Concentric needle electrodes were inserted at six points in the mouth for EMG readings. Oral exercises,(which included: entire smile, smile on the left side of the mouth and then the right side, labial eversion, counting, and phoneme and diphthong repetition) were also evaluated and graded for tonic activi- ty, amplitude and frequency, and symmetry of labial move- ments. The results suggest that levodOpa was the superior drug for benefiting speech. Significant improvement was noted in labial eversion, counting, and phoneme and diphthong repitition for both procyclidine and levodOpa. Also with levodOpa, benefits in symmetry, amplitude, and fre- quency of labial movements were noted. 23 Parkinsonian Dysarthria The characteristics of dysarthria are described in detail in the literature: Zentay (1937); Perello (1958): Aronson et a1. (1968); and Darley et a1. (1968). Mueller (1971) makes the following general conclusions regarding dysarthria: 1) the neuromuscular pathology underlying dysarthria appears to affect, to varying degrees, not only the articulatory but the phonatory and respiratory process of speech as well, 2) there are implications that the site and extent of the lesion determines, to a large extent, the speech pattern of the dysarthric, and 3) the need for further physiological research in dysarthria is obvious--especially the kind of research comparing various etiological groups of dysarthric individuals with one another and to the normal population (p. 333). Darley, et a1. (1968) list seven subcategories of dysarthria: spastic, flaccid, combined spastic and flaccid, ataxic, hypokinetic, and two forms of hyperkinetic (quick and slow). Each of the above forms are reported to have unique combinations of deviation of the five basic motor speech processess: respiration, phonation, resonance, articulation, and prosody. According to the authors, parkinsonism produces "hypokinetic dysarthria" which: . . . almost exclusively, is associated with repe- tition of initial sounds of words. This error suggests the occurrence of speech arrests analo- gous to the motor arrests observed in walking. Unusual prolongation of sounds is most frequently found in cerebellar disorders, where the timing of movements is faulty; however, one is likely 24 to hear prolongation of speech sounds in the hyperkinetic disorders and indeed in any patient whose rate of speech is substantially slowed. . . (p. 840). Darley et al. (1969a), in an analysis of 32 patients with parkinsonism, found monopitch, monoloudness, and reduced stress to be the most striking phenomena in parkinsonism's hypokinetic dysarthria. Also, according to the authors, hypokinetic dysarthria is the only type of dysarthria in which the rate is not characteristically slow. As a group, hypokinetic dysarthrics are rated slightly faster than the other dysarthrias. Darley et al. (1969b) chart the neuro- muscular effects seen in the dysarthrias. Table 1 shows the relationship between hypokinetic dysarthria and the other forms: CLR (cerebellar ataxia--ataxic dysarthria), PBP (pseudobulbar palsy--spastic dysarthria), BUL (bulbar palsy--f1accid dysarthria), ALS (amyotrophic lateral sclero— sis--combined spastic and flaccid), PKN (parkinsonism--hypo- kinetic), DTN (dystonia--hyperkinetic) and CHO (chorea-- hyperkinetic). Tikofsky and Tikofsky (1964), in an intelligibility study of dysarthric speech, concluded that intelligibility testing can be employed to evaluate dysarthric speech. The authors were able to differentiate among dysarthrics in terms of listener based judgments and that intelligibility scores for normals differed markedly from the dysarthrics. .383 4... am .838 "mousom 25 888“ 83888 6838 AESSBV 6838 6838 9880 80.338 93808 305me gammmoxm 9389.6 I8 8.30 383 93808 3968”” 38.3352 mo 8:8. 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Brombart (1961) reported hesitant deglutition at the buccopharyngeal region in 5 of the 18 parkinsonian cases. Massengill (1967), in a cinefluorographic study, reported tongue thrusting patterns in all five parkinsonian patients studied. The author also reported that all five cases had experienced some difficulty swallowing. Logemann et a1. (1973), in another cineradiographic study, reported that 12 of the 25 patients studied had lingual articulation dis- orders. According to the authors, "The lingual disability progressed from posterior to anterior, with labial involve- ment beginning sometime after posterior involvement of the tongue was evident" (p. 277). The authors conclude that lingual disability first affects swallowing and progresses to affect lingual mobility for speech and gradually moves from a posterior to anterior position. Diadochokinetic rate is an effective measure of bradykinesia (abnormal slowness of movement) of the oral mechanism. It is known that the average diadochokinetic rate for normals is seven movements per second. Buck and Cooper (1956) measured the lingual diadochokinetic rates of 48 patients with Parkinson's disease and found that 27 three fourths of them had slow rates of 4 to 5 lingual alveolar movements per second. Although a "trend toward an association between a poor diadochokinetic rate and severe speech involvement" was noted, no significant relationship was found. Canter (1965) compared diadochokinetic perform- ances of 17 parkinsonian patients with that of an age-matched group. He concluded that the parkinsonian group had impaired ability to perform rapid movements of the tongue tip, back of the tongue, lips, and vocal folds. The tongue- tip involvement was observed to be typically greater than the lip involvement. It was observed that diadochokinesis was highly correlated with clarity of articulation, which was in turn highly correlated with over-all Speech adequacy. Kreul (1972), in a study consisting of 23 patients with parkinsonism and control groups, concluded that syllable diadochokinetic rates fail to differentiate between normal subjects and subjects with parkinsonism. The author did however, deter- mine that diadochokinetic rates for an interrupted vowel /i/ and a repeated vowel glide /u-i/ did differentiate between the two groups. In general, labial muscles are normally activated in two functionally antagonistic groups for the production of rounding/closing and opening/Spreading gesture movements (Leanderson et a1. 1971). Parkinsonism affects the reciprocal innervation of the limb musculature (Schneider, 1968) and it has been suggested that the same type of disturbance 28 occurs in the facial musculature (Leanderson et al., 1972). In their study, it was revealed that a progressive articula- tory deterioration of the stop consonants existed in patients with parkinsonism. Six muscles in one-half of the face were investigated and EMG examination indicated a well pre- served reciprocal activation pattern initially. However, the second EMG examination revealed that the /b/-implosion involved no inhibition in the lip-opening muscles. The authors conclude, "Obviously, a deficient reciprocal activation seems to be the prime factor for the misarti- culation of labial stop consonants, the production of which demands rapidly alternating closing and opening speech gesture components." In addition, L-Dopa was found to re-establish the reciprocal activation as well as reduce_ the hypertonicity in the subjects. Netsell and Cleeland (1973) report considerable success in removing undesirable lip retraction by using EMC feedback in one subject with complete bilateral retraction of the upper lip. Darley et a1. (1968) consider the articulatory errors in parkinsonism to be highly consistent. Darley et a1. (1975) report that, "In the hypokinesia of parkinsonism, efficiency of articulation is diminished, since the range of movements is narrowed, the speed of single movements slowed, the speed of repetitive movements increased although their range is limited, and the force of movements reduced" (p. 187). 29 Doshay (1960) reports "slurred articulation" to be the most serious type of speech disturbance occurring in individuals with Parkinson's disease. Hoberman (1958) found labial and alveolar consonants to be the most defec- tive phonemes found in the speech of parkinsonism. Hoberman suggests that parkinsonian patients perform normally for isolated voluntary movements and poorly for speech. Cramer (1940) reports that plosives lacked precision and were produced almost like fricatives in a group of post- encephalitic parkinsonian patients. Canter (1965) also found imprecise production of plosive consonants and dis- coordination of phonatory and articulatory activity to be the main contributors to the defective articulation in his group of 17 patients with the disease. In a long term study to measure the effects of parkinsonism on control of the vocal tract, Logemann et a1. (1973) observed fricatives to be produced with a reduction of constriction of the air channel. Radiographic analysis indicated that, "The tongue elevation was reduced in production of the affected speech sounds so that step consonants . . . were converted to 'almost contacted' fricatives, produced at the same place of articulation" (p. 278). Effects On Respiration A number of studies deal specifically with the respi~ ratory disorders in parkinsonism. Schilling (1925) reported respiratory deficits for both vegetative and speech 30 functions in a study of eight parkinsonian patients. Cramer (1940), in a study of six post-encephalitic parkin- sonian patients, found 1) twice the normal frequency of in- halation, 2) negligible differences between vegetative breathing, profound breathing, and respiration during oral reading, 3) smaller than average vital capacities, 4) wastage of air before speaking, and 5) exhalation re- peatedly interrupted by small inhalations. Laszewski (1956) attributes the speech deficits in most cases of parkinsonism to rigidity of the articulatory muscles than to restriction of vital capacity. Smith (l964),in a study of 23 parkinso- nian patients, supports Laszewski's view by reporting a non-significant correlation (r = .05) between judged severity of speech defectiveness and vital capacity. Ewanowski (1964), in a study of 12 female parkinsonian patients, found no significant difference between quiet respiratory patterns between a parkinsonian group and a control group. He did, however, report that those with more severe neurolo- gic impairment had faster respiratory rates. Nugent et al. (1958) report decreased maximum breathing capacity and dyspnoea in 50 percent of parkinsonian patients. De La Torre et a1. (1960) also reported reduced breathing capacity in 50 percent of the patients with the disease. In a study involving electromyography, Petit and Delhez (1961) found that the intercostal muscles interfered with respiratory function. The authors reported that the diaphragmatic 31 muscles appeared normal or near normal. Kim (1968), in a study of post-encephalitic parkinsonism, found respirometer tracings that indicated that during the resting state the patients had more rapid respiration with fewer variations in amplitude than the normals. The author considers the most significant finding to be that the post-encephalitic parkinsonians were limited in their ability to interrupt automatic aspects of respiration by volitional control as demonstrated by inability to hold breath. Effects On Phonation Most observations of the speech of parkinsonism refers to phonatory deficits. Merritt (1955) concluded that re- duced loudness is a frequent characteristic of parkinsonism. Darley et a1. (1968) observed reduced stress and monoloud- ness to be one of the major characteristics associated with the disease. Darley et al. (1969b) found two voice quality deviations, harshness and continuous breathiness, in their study of 32 adult subjects with parkinsonism. The authors attribute the occurrence of harshness, breathiness, and low pitch to the rigidity of laryngeal musculature. A high vocal pitch has been reported by Nielson (1941) and Grewel (1957). Merritt (1955) however, observed a low voice to be associated with the disease. Canter (1963), in a well controlled study, measured the pitch levels (oscillograph) of 17 male patients with the disease and found that the parkinsonian group spoke at significantly 32 higher pitch levels than the age matched control group. The patients spoke at a median fundamental frequency of 129 cps on the average, while the control group was 106 cps. Canter (1965) compared aged matched male parkinsonian patients with a control group in 1) their ability to produce different levels of vocal intensity, 2) the ability to phonate at extremely low and high pitch levels, and 3) to sustain phonation. To measure vocal intensity the author had each subject produce the syllable /no/ five times at four different levels of loudness: quiet, average, loud, and shouted. The readings were taken from a sound level meter. To determine vocal pitch measures, the subjects were in- structed to produce the syllable /no/ at various pitch levels and ossillograms were made for measurement purposes. Sustained phonation was measured by having the subjects sustain the vowel /a/ three times in succession for as long as possible on a single breath. Canter concluded the follow- ing from the study: 1) The parkinsonian patients, as a group, were unable to produce "quiet" phonation at levels as low as those achieved by the control subjects. On "average" phonation, the two groups were essentially the same. The majority of the patients showed reduced ability to produce "loud" and "shouted" phonation. 2) Reductions in maximum pitch ranges were typical of the parkinsonian group. The parkinsonian patients averaged 1.25 octavies as compared to 1.84 for the controls. 3) The ability to sustain phonation 33 was impaired in the majority of the parkinsonian subjects (p. 49). Darley et al. (1969b), in a study of 32 adult subjects with parkinsonism, reported monotony of pitch in 31 patients, monotony of loudness in all 32 of the subjects. Further, reduction of variability in pitch and loudness was reflected in the subjects' use of proper stress. All 32 subjects were judged to show some reduction of prOper stress for emphasis. Mueller (1971), in a study of ten patients with Parkin- son's disease, matched them with a control group and found the parkinsonian patients to be reducedbin the following areas: 1. Phonation time during the sustained phonation of the vowel /a/o 2. Amount of air expended during the sustained phonations of /a/, 3. Phonation time for repeated productions of the syllable /s‘/: 4. Total number of syllables produced for repeated productions of /s“/, 5. Intraoral pressure during /SA/ productions. Mean oral airflow rates and volumes of air expended during repeated utterances of /so/ did not differ statistically from the control group. However, the author suggests that the differences were indicative of respiratory and/or glottal 34 inefficiency in Parkinson's disease. The author concludes that the neuro-muscular involvement precludes the indivi- dualwsability to generate sufficient amounts of aerodynamic energy necessary for normal phonation and articulation. Acoustic Aspects Of Dysarthric Sppech Lehiste (1965) analyzed the acoustic characteristics of dysarthric speech. Test material included three word lists for measurement purposes: 1) fifty monosyllabic ‘CNC words, which are monosyllabic words with an initial and final consonant phoneme, 2) sixty monosyllabic words con- taining a number of initial and final clusters, and 3) fifty spondee words. The following measurements were made on each spectrogram: l. The center frequency of the first three formats at the target or steady state of the syllable nucleus. 2. The duration of the syllable nucleus. 3. Formauzpositions at the point of transition form the initial consonant to the syllable nucleus and at the point of transition from the syllable nucleus to the final consonant. 4. The duration of the initial and final consonants. 5. The formant positions within the resonant consonants. 6. The frequency of energy concentrations in fricative consonants and in the releases of plosives. Conclusions drawn from the study are as follows: Deviations due to insufficient control of the voacl folds: l. Laryngealization of syllable nuclei, 2. Laryngealization of consonants, 3. Breathy segments, 4. Voiceless transitions, 5. Devoicing of resonants. Deviant pronounciations due to lack of control of the velum: l. Denasalization of initial consonants, 2. Denasalization of final consonants, 35 3. Nasalization of syllable nuclei, 4. Nasalization of non-nasal consonants. Deviations in articulation: l. Palatalization, 2. Retroflexion, 3. Neutralization of the fortis-lenis opposition, 4., Distortions in the manner of articulation, 5. Distortions in the point of articulation, 6. Distortions in timing. Lehiste reported the detailed articulatory deviations in the one Parkinson subject: A considerable number of the distortions in the articulation of consonants involve changes in the manner of articulation. A sibilant /s/ was mani- fested as (O) (as in Epink) three times in initial position and seven times in final position. A bilabial voiceless fricative was produced in the words house and toss. The bilabial voiceless frica- tive was also once substituted for final /z/. Other substitutions for final /z/ included two occurrences of (O) and one occurrence of (f) (as in gpip). On the other hand, the sibilant /s/ was substituted for the final consonants in the words with and forth. A fricative was substituted for a plosive in nine cases. . . . The voiced velar fricative was also used once to replace final /r/ and once in place of initial /y/ (p. 57). Lehiste also reported occasional substitution of glottal stops for final /t/ and /k/ phonemes. Legiste concludes that dysarthric subjects occasionally insert a pause in a sequence which does not correspond to a break between words. She observed the misplacement of the word boundary in spondee words in four instances. Durational Qualities Some authors have concluded that slow rates of speak- ing are common among parkinsonian patients (Brain, 1951: Grewel, 1957). Canter (1963) studied the durational 36 qualities of parkinsonism. 'He suggests that an individual's speaking rate depends on 1) the number of pauses, 2) the length of the pauses, 3) the length of the phrases, and 4) the duration of the spoken syllables. In his study, a pause was defined as the stoppage of speech. The duration was measured for each pause and the averaged values provided the "mean pause length." The length of a phrase was obtained by determining the time elapsed between successive pauses. Finally, syllable duration was measured using a phonation timer described by Steer and Hanley (1957). The study of 17 male parkinsonian patients and 17 male control subjects found the median speaking rate of the parkinsonian patients to be 172.6 words per minute as compared to 177.6 words per minute for the control group. Rate of speaking was determined by the time required to read the "Rainbow Passage" (98 words). However, statistical analysis revealed the differences in the two frequency distributions to not be reliable. Canter also did not find a statistically significant difference on the four measures of speaking rate. However, he did note individual cases of extreme deviation. Summary Individuals with Parkinson's disease comprise approxi- mately 2 percent of the patients with neurological disease. The typical symptoms of muscular rigidity, tremor at rest, and impaired voluntary movements, influence to varying 37 degrees the speech production ability of these patients. It is believed that any dysfunction of the extrapyramidal system can result in Parkinson's disease. Abnormally low concentrations of dopamine, norepinephrine, and serotonin in the basas ganglia and hypothalamus suggest a deficit in the binding of amines. Most research indicates some psychological reactions to the disease. The studies, however, do not agree on the specific psychological deficits that accompany or result from the disease. Depression and emotional lability are frequently reported. Many of the psychological reactions in Parkinson's disease are reported to be a combination of disease, age, and large doses of medication. Language and auditory deficits have been reported. The language deficits are generally reported to accompany subcortical surgery for the relief of the parkinson symptoms. The results of the studies differ regarding the existence of language deficits in unoperated patients. The research regarding auditory deficits indicates that Parkinson sub- jects do not differ fron normals on pure tone and convention- al tests. There is, however, some evidence that auditory de- ficits may be detected with more difficult auditory tests. The dysarthria seen in Parkinson's disease has been labeled hypokinetic dysarthria. Deficits in respiration, phonation, resonance, prosody, and articulation have been reported. The verbal symptoms in Parkinson's disease are 38 often quite variable. Rapid fluctuation of symptoms have long been recognized. These "on-off" attacks have been reported more frequently since the introduction of L-Dopa and have been linked to excessive plasma concentrations of levodopa. The "acceleration phenomena," or short rushes of speech, have also been reported to accompany Parkinson's disease. Studies indicating specific symptoms of monopitch, monoloudness, imprecise production of plosives, and reduced oral diadochokinesis in Parkinson's disease have been reported. The above deficits are reported to contribute to an overall reduced intelligibility. There are no published studies involving spectrographic analysis of hypokinetic dysarthria. One spectrographic study of general dysarthria utilized a Parkinson subject in the sample. The author reported distortions of timing and confusion of word boundaries to be some of the characteris- tics associated with the Speech of that subjects. The recent widespread use of L-Dopa therapy and other anti-parkinson medication has resulted in reports of modest gain to complete arrest of the disease. Generally, reports indicate measurable improvement in most individuals. Specific improvement in intelligibility and labial movements has been reported to result from the anti-parkinson medica- tion. Today, most patients receive anti-parkinson medication for relief of the Parkinson symptoms. CHAPTER III SUBJECTS, EQUIPMENT, MATERIALS, AND PROCEDURES To reduce the confusion that may arise from a discus- sion of the apparatus and procedures employed in the four analyses, this chapter is divided into five sections. Section I, General Procedure, describes subjects, apparatus, and the procedure employed to collect speech samples from the Parkinson subjects and the control subjects. Section II, Pause Analysis, discusses the procedure and equipment employed in the detection and measurement of the articula- tory pauses from these samples. Section III, Spectrographic Analysis, describes Spectrograms from the speech samples and the procedures used to measure the mean frequencies of the first and second formants of seven vowels. Section IV, Intelligibility Analysis, discusses the apparatus and judging methods used in determining the overall intelligibility of the Parkinson subjects. Section V, Plosive Analysis, is divided into two parts. Part A concerns the procedure used to determine how the judges perceived the vowel-bracketed plosives. Part B explains the procedure employed to determine whether there was a significant difference between the Parkin- son subjects' and control subjects' production of isolated- vowel bracketed plosives as determined by untrained judges. 39 40 Section I: General Procedure Subjects A total of 24 subjects were utilized in this study. All subjects spoke Standard American English of Midwestern dialect. Twelve of the subjects, six male and six female, were diagnosed by their physicians as having Parkinson's disease or parkinsonism. Each sex category was further subdivided into those diagnosed by their physicians as displaying severe Parkinson symptoms and those displaying mild symptoms. The subjects with Parkinson's disease were referred by their physicians or located from nursing home records. Seven of the twelve Parkinson subjects resided in nursing homes or medical care facilities. All subjects with Parkinson's disease were receiving anti-Parkinson medication and were history free of concomitant brain damage or other central nervous sytem dysfunction. A control group, also histOry free of brain damage or central nervous system dysfunction, was sex and age matched (1 3 years) with the Parkinson group. The Parkinson group mean age was 72.58 with a standard deviation of 10.67 years. The control group mean age was 72.50 with a standard devia- tion of 11.25 years. Table 2 lists the Parkinson and control subjects by age, sex, and severity of involvement. 41 Table 2. Parkinson and control subjects by age, sex, and severity of involvement. Parkinson Subjects Control Subjects Name Sex Age Name Sex Age A.F. F 84 L.G. F 84 Severe G.R. F 78 B.C. F 77 L.W. F 81 G.C. F 82 M.L. F 72 A.D. F 74 Mild B.F. F 72 J.M. F 72 B.R. F 49 8.8. F 46 C.R. M 86 C.F. M 83 Severe C.D. M 71 R.M. M 74 J.K. M 70 W.W. M 72 B.S. M 68 J.W. M 68 Mild H.B. M 81 L.S. M 81 E.P. M 59 B.B. M 57 Apparatus The following apparatus was employed in the collection and analysis of the data: 1. Sound Spectrograph (Voice Identification, Inc., VII, Series 700). 2. Pausimeter (Tosi, 1965). 3. Timer-Counter (Hewlett-Packard, 5326B). 42 4. High Speed Digital Printer (Mohawk Data Sciences Corp., Model 1200). 5. Open Reel Tape Recorder (Ampex Model AG600). 6. Amplifier and Speaker (Ampex Model 620). 7. Portable Cassette Tape Recorder (Sony Solid State #110). 8. Audio Training Cassette Tapes (Memorex). 9. Magnetic Recording Tapes (Scotch AV 176, Low Noise). 10. CDC 6500 Computer. Speech Samples The following speech samples were used in this study: 1. The Rainbow Passage: A widely used, phonetically balanced passage presented in Appendix A. 2. The Multiple Choice Test of Intelligibility py B1225 (1963): List C was used and a sample of the form and scoring sheet is presented in Appendix B. 3. Cluster and CNC monopyllables: Monosyllables of a consonant-vowel-consonant variety. Complete lists are provided in Appendices C and D. 4. Vowel-bracketed Plosives: Four plosiVes /t/, /d/, /p/, and /b/ were bracketed by the vowels /I/, /a/, /u/ and are presented in Appendix E. All samples were recorded on Memorex Audio Training Cassettes using a Sony Solid State Portable Tape Recorder #110. The samples were obtained at the subjects' place of 43 residence. Room ambient noise levels were kept at a minimum. In the laboratory, the speech samples were trans- ferred from the Audio Training Cassettes to the Open Reel Magnetic Recording Tapes using the Ampex Model AG600 Reel Tape Recorder. Section II: Pause Analysis The purpose of the pause analysis was to determine whether there was a significant difference between the Parkinson subjects' and normal subjects' duration of articulatory pauses. Two minute samples of the subjects' reading of the Rainbow Passage (Appendix A) were used as the sample of on- going speech. The tapes containing the Rainbow Passage were edited to remove any external noise. The operational defi- nition of a pause, the method of pause detection, and the method of measuring the duration of a pause proposed by Tosi (1965) was followed in this analysis. Tosi (1965) defined a pause as: . . . flow of acoustic energy of which the relative amplitudes remain below a predetermined value of a parameter called 'pause maximum amplitude, L ,' provided the duration of such levels of amplitgde is more than a predetermined amount of time, indicated by another parameter called 'pause-mini- mum duration, T .' The parameter L is expressed as a percentage or dB ratio with respegt to the average peak amplitudes (pressure or voltage) of the rectified waves of the sample of sound analyzed. The parameter Tp is expressed in milliseconds (p. 134). Figure 1 illustrates the above definition. The speech wave is represented before and after rectification. According to Tosi's (1965) operational definition, only 44 .coflumoflmfiuowu umuwm paw mu0wwn m8>m3 cowwdm mo uoHd mpsufladfiénmsfle .H mnsmam “momfiv «woe "wousom : o .1 m o o m 4 L. 5.2 4 Y V #242 .8 A 4 #242 x Pz 78268 3.3.: _ .828. _ _ _ _:I : tit: _ __ _ _ _ _ _ 9.939. +_.+m><3,fl.mpz_u I _ _ s l _ _ . qu . . ..— ._ _ a» ._ . -.:<:‘.< I‘l- .1 a z = z. manhjds—d ( 5: < I moat4dzu8ucH .8>m3 m cflnufl3 musmmmud mo mH8>8H 30H 8>flumeu umw>m3 QQSOm waQEoo cfinuflz zmdmm m>mzmuucH= .N musmflh Ammmav «woe "mousom — «i Tlllll 33.. “122352. b 09me F"""""" <86 2.... mosh—4&5? 47 duration of less than 10 and 6.6 milliseconds respectively (Tosi, 1965). Most pauses are longer than these durations. Thus, the second parameter, pause-minimum duration (Tp), is needed to define the other boundary of a pause. In this study it was adopted that Tp = 5 milliseconds because at this minimum duration interwave gaps were avoided for all the subjects' speech waves. Tosi (1965) labeled and described the device and asso- ciated instruments for detecting and measuring pauses from ongoing speech as a "pausimeter." A block diagram of the instrument is provided in Figure 3. The Ampex AG600 Reel Tape Recorder, playing back the Rainbow Passages, is connected to Block I of the pausimeter. Block I consists of an amplifier, an attenuator, and a rectifier. According to prescribed methods of operation, the amplifier or attenuator was adjusted so that the average amplitude peaks of the speech remained at approximately 0 level as indicated by a panel instrument. The output of Block I, consisting of the rectified speech waves with their peaks at a level of approximately 14 volts, is connected into the input of Block II. This unit consists essentially of three Schmitt trigger circuits. The first one, Sc' is activated only when the relative amplitudes of incoming rectified waves of the original sound are smaller than the value of Lp or greater than the value of LS selected on a decade dial on the panel of the pausimeter. The output of 48 .mucwcauumcw wouMHUOmmm 0cm nmumemnmm 8:» mo Emummfip xoon .m 8.3ka “T_ Aqug HmOB quHDom unaccomz 02.5.5. N xupzaoo amazouum 4d/F Sums of Squares Mean Squares F-Ratio Sex 3504.817 3504.817 .34289 Severity 1 53651.139 53651.139 5.2489* Interaction 1 898.562 898.562 .0879 Error 8 81770.644 10221.331 * 5.32 required for significance at the 0.05 level of confidence. Two additional two-tailed T-Tests were computed. The first T-Test (T = 0.0663) compared the six severe Parkinson subjects with their respective controls. The results of this test indicated non-significant differences beyond the 0.05 (2.571) level of confidence. ‘The second test (T==2.1897) compared the mild subjects with their respective control subjects and the differences were non-significant beyond the 0.05 (2.571) level but significant beyond the 0.10 (2.015) level of confidence. The results of the Pause Analysis do not allow complete rejection of the hypothesis that there is no difference between Parkinson and normal subjects' duration of articula- tory pauses. Significant differences were obtained at the 0.10 level of confidence and at the 0.05 level of confidence using the one-tailed T-Test. 63 The test hypothesis used in the Pause Analysis was purposely stated in non-directional terms because there was no previous research to indicate that Parkinson subjects would have longer or shorter articulatory pauses. It was thought, however, that because Parkinson subjects have generally reduced energy levels for walking, talking, and other motor functions, the mean articulatory pause (low energy levels) would be longer. However, the fact that there was an observed tendency for the control subjects to have longer mean pauses is not surprising, considering the observation by Darley et al. (1969a) that hypokinetic dysarthria is the only type in which the rate of speech is not characteristically slow. Thus, if the general rate of speech is faster, it seems plausible that the duration of articulatory pauses would also be shorter. The indication that the control subjects displayed longer mean articulatory pauses than the Parkinson subjects may be related to the Acceleration Phenomenon observed in the Parkinson syndrome. Generally, the Acceleration Pheno- menon is considered as "occasional" occurrences of rapid speech. The Pause Analysis suggests that the tendency for rapid articulatory patterning or acceleration may be present during all or most ongoing speech of the Parkinson subjects. Netsell's et a1. (1975) hypothesis, that the speech articula- tors fail to reach the intended position before beginning the movement for the following sound may explain the 64 observation of shorter articulatory pauses in the Parkinson subjects. If the Parkinson subjects undershoot the articu— latory positions, then the distance between BC and EF, as seen in Figure 1, would be necessarily shorter. These distances would be shorter because the high energy levels for the following sound would begin sooner--thus, shorter mean articulatory pauses. Because the results of the Pause Analysis were only marginally significant, cautious acceptance of the above discussion is recommended. Spectrographic Analysis The purpose of the spectrographic analysis was to deter- mine whether there was a significant difference in the Euclidian distances between the mean frequency of the first and second formants of vowels uttered by Parkinson subjects and the same vowel uttered by normal subjects. Table 6 indicates the average mean frequency of the first and second formants for each vowel. The Euclidian distances between points determined by the mean frequency of F and F of each vowel, uttered by each subject, and the l 2 centroids determined by the average means for each subgroup of subjects were computed. A statistical analysis performed with these Euclidian distances showed no significant differences among subjects of each subgroup. Euclidian distances for normal subjects were submitted to the same treatment with similar results. 65 muw>8m m8 com 82 0mm mm: 08 mm: 08 mm: Gm 92 QB 53 com 9:35qu Sm 84 Ga com 32 .8 82 Go $3 mm 22 0mm 22 8.. 3a: 3...: m.comcflxumm NR «3. mmm 58 22 NE 82 .8 mm: mam mmS mum 92 mg 8502 . muw>8m 8A 85 83 mm... 83 m8 9: 02. SH Gs 2mm Sm 92 m2 Paomfixumm mmm mm... 83 8m 22 So 82 A: mmam Gm omom Se 58 $4 3:. 365mm m.comcflxumm mam mo... 33 8o 83 omo mm: was $3 wow 82 wow 53 mom 3.502 mm ah mm as mm Hm mm Hm mm HE «m an «A an 0 mm .mucmfiuom paw paw uma mo mwflocmsvmum :mmE mmmum>¢ .m magma 66 Another statistical analysis showed that the Euclidian distances corresponding to the Parkinson subjects differed significantly in almost all cases from the distances of normal subjects for all vowels and subgroups studied. The Parkinson subjects' deviations, however, were not consistent. For instance, Table 6 indicates that the vowel /ae/ uttered by both female and male Parkinson subjects, with either severe or mild diagnosis, present average mean frequencies of F1 smaller than the normals. In other cases, like the vowel /a/, the average for F1 is larger for both males and females with either severe or mild diagnosis than for normal averages. The vowel,&e/ showed a decrease of F1 and F2 proportional to the Parkinson severity. Although no interaction was observed across the various subgroups, there was some homogeneity between vowel- sex-formant number-type of diagnosis with the amount and direction of the Parkinson groups' frequency deviation re to normals. However, the reduced pOpulation of subjects used in this study does not allow a solid conclusion regarding this aspect. Comparison of the mean frequencies of F1 and F2 of each vowel studied from the normal subjects used in this study and normal subjects used in other studies, indicated no significant differences in spite of the fact that the sub- jects used in this study were older than those utilized in other studies (Gray and Wise, 1958). 67 Intelligibility Analysis The purpose of the intelligibility analysis was to determine whether Parkinson subjects differed significantly in intelligibility from normals as measured by the Multiple Choice Intelligibility Test by Black (1963). The normal- ized percentage of answers should reach 100 percent for normal speakers and normal listeners using a good audio system. The percentages obtained for Parkinson subjects, as judged by untrained listeners through the linear response system, are listed on Table 7. All of the percentages were submitted to a statistical test (analysis of variance). Results indicated a significant difference (0.01) re to the normal percentages of intelligibility. Table 7. Intelligibility of Parkinson subjects in percent. Sex Severity Subjects Percent Average Percent 96.13 Mild 96.00 H = 94.35 90.91 SD = 5.21 Male 88.94 Severe 90.30 u = 78.45 56.11 SD = 18.05 91.91 Mild 87.86 H = 90.30 92.96 SD = 6.28 Female 95.30 Severe 67.18 0 83.90 89.13 SD 14.25 68 The percentages indicated by the judges of this test (3 for each subject) determined that there was not a signi- ficant difference among the judges. This was interpreted as an indication of the reliability of the test. The results of the intelligibility analysis suggest that Parkinson subjects, diagnosed by their physicians as possessing either mild or severe involvement, will have reduced intelligibility related to the severity of the disease. The decreased intelligibility of the Parkinson subjects must be attributed to articulation since the loudness levels were adjusted to a fixed volume in each case. Subjects with a severe diagnosis possess an intelligibility significantly less than the normals (up to 22 percent reduction). Subjects with a mild diagnosis present a reduction of only up to 10 percent re to the normal. The results of this analysis also suggest that women with a severe diagnosis have better intelligibility than men with the same condition, and vice versa for subjects with a mild diagnosis. Plosive Analysis The purpose of the Plosive Analysis Part A was to determine how untrained judges perceived the vowel-bracketed plosives produced by the subjects with Parkinson's disease. The data for all subjects is presented in Table 8. Overall. the judges were correct in their responses to the vowel- bracketed plosives on 80.3 percent of the items. Of the 69 wm I: we wHH wow wooa wm II we wHH wva wow wooa AA H OH mm mm mva hmm Hmuoa wm wH wh wva wma whm wooa mm>amon UmOHo> m H h «a ma mm Hoa wm wo wm wm wma was wood mo>amoam omowo>cb m o m HH we om mma m m m m m m mm a mm>a moan mm>Hmon mm>wmon Houum Hmm 2 H .H U. 4H U .H0 .4... . .m UmUflONVCD Mumoflo> HMUOB .muowhnow downwxumm Ham Mom momoon #anm an mammm: pom .mamumumH .mmpwam .mw>HumoHHm .mw>flmon owowo>co .mo>wmoam owoflo> mm om>flmoumm muouuw mo usmoumm com uwQEsz .m magma 7O errors listed by the judges, 80 percent were perceived as other plosives, 11 percent as fricatives, 5 percent as nasals, and 4 percent as glides. Table 9 indicates that, of the errors in the severe category, 74 percent were per— ceived as other plosives, 11 percent as fricatives, 7 per- cent as glides, 7 percent as nasals, and 1 percent as laterals. Table 10 indicates that, of the errors in the mild category, 86 percent were perceived as other plosives, 12 percent as fricatives, 1 percent as glides, and 1 percent as nasals. The results of the Plosive Analysis Part A supports Cramer's (1940) and Canter's (1965) observation that plosives lacked precision and were produced almost like fricatives. The untrained judges perceived plosives as fricatives on 11 percent of the stimuli. However, judges were signifi- cantly more consistent in confusing some plosives as other plosives. The trend was especially evident in the judges' perception of unvoiced plosives as voiced plosives. In addition, subjects diagnosed as severe by their physicians tended to have more errors listed as nasals (7 percent) than those diagnosed as mild (1 percent). However, judges perceived plosives as fricatives equally between the mild (12 percent) and the severe (11 percent) categories. The purpose of Part B of the Plosive Analysis was to de- termine whether there was any difference between the Parkinson subjects' and the age-matched control subjects' production 71 wh wH wh wHH wvs wooa wh wa wb wHH me wmm wooa OH H m «A ma mu HmH Hmuoa wm wa woa wma wva whm wooa mm>wmon woao q H s m OH as «a c . > woa II wm wm wma wmo wooa mm>wmoam moao>c m -u m m a pm mm c . a mw>Hmon mm>wmoam Houum mammmz mamumumq mmpwao mm>flumoflum omowo>co cmoa0> Hmuoa .muoanSm cOmcwamm mnm>mm How momoon usowm an madman cam .mamnmuMH .wmowam .mw>wumowum .mw>flmon pmowo>co .mw>flmon pmowo> mmfium>fimouwm muonuw mo usmouma pom Honfisz .m wanna 72 wH II wH wNH wow wooa wa II wH wNH wma wmn wooa H o H Ha ma on mm Hmuoe wm II II wna wHN wmm wooa mo>flmoam moao H o o m m 2 mm o .> II II wm wm woa was wooa mw>flmoam wmowo>co o o a m 5 mm no mm>flmon mw>flmon Houum mammmz mamuwumq mopfiau mm>aam0aum pmowo>cb ww0flo> Hmuoe .muomnnom somcwxumm pawe How mmmpsm “swam an mammmc pom .mamumumH .mmpfiam .mw>fiumoflum .mm>flmon Umoflo>co .mm>fimon pmofio> mm pm>flmouwm muouum mo uswouma paw HmnEoz .oa wanna 73 of vowel-bracketed plosives as determined by untrained judges. Analysis of the data suggests that untrained judges perceive isolated vowel-bracketed plosives with equal efficiency between the Parkinson subjects and the age- matched control group. Table 11 indicates the total correct and the total errors for each subject in each category. Overall, the judges were correct in their responses to the vowel-bracketed plosives on 81 percent of the items. This compares to the 80.3 percent correct response rate as reported in Part A. Thus, both methods of plosive analy- sis, open and closed response, were considered as equal indicators of the judges' perception of the vowel-bracketed plosives. The mean, variance, and standard deviation for the Parkinson group was 29.17, 33.06, and 5.75 respectively. For the control subjects, the judges were correct in their responses on 78 percent of the items. The mean, variance, and standard deviation was 28.08, 22.81, and 4.78 respec- tively. A difference between means T-Test showed the control score not to be significantly higher at the .05 level of significance. In addition to the anlaysis for all Parkinson sub- jects, overall comparisons were made between severe and mild Parkinson groups and their respective control groups. Table 12 indicates that the mild and severe Parkinson groups, when compared to their control groups, were equally 74 .mmmosm moan» Eoum magmawm>m mwmcommmu mo Hogans Hmuoe « o.mh mm 5mm va Hmuoa o.Hm mm 0mm va HmuOB o.mh m mm mm .m.m m.mm w mm mm .m.m UHHE 2 o.mh m mm mm .m.A «.mm HH mm mm .m.0 GAME 2 m.mm v mm on .3.b h.Hm m mm mm .m.m CHAS E h.Hm m mm mm .3.3 H.0m m Hm mm .M.b mum>mm Z o.mh m hm om .2.m h.Hv HN ma mm .Q.U mum>0m E m.mm 0H om mm .m.U h.Hm m mm mm .m.U mum>mm S N.hm H mm mm .m.m m.mm v mm mm .m.m flaw: m m.mm m cm mm .Z.h m.mm v mm mm .m.m flaw: m m.mm v mm mm .D.4 w.om 5 mm mm .A.S UHHS m m.mm ma om mm .U.w N.hm H mm mm .3.A mum>mm m ¢.mm HH mm mm .U.m H.Hw «H mm mm .m.0 mH0>mm m m.om h mm mm .0.A H.0m m Hm mm .m.< mum>mm m % m. mo we womflgm % M m M vomnnsm cofiuwoflm xmm D o 1 s Houucou 3 o 1 s cOmcwxumm IHmmmao o o 1 s o o 1 s 1 1 e t. 1 1 e t. 1 1 o a. 1 1 o q a a 1 I a e 3 .L o o a o o a 1.. 3. 8. 3. 1. x. .muomnnom Houucoo cam muomnnom somcflxumm mom uomunoo Hmuoa .HH manme 75 m.~¢ mam mm mma mam mHouucoo cmnuumsumma m.~¢ mam mm mma mam muommnsm comcfixnmm paw: m.mm mam mm «ma mam maouucoo cmnoumsumma m.hm mam mv vwa mam muomnnom GOmcqumm mum>mw o.mn «me mm 5mm «me whomhnsm Houucoo Haa o.am mmv mm omm mmv muomflnsm aomcflxumm Haw uomuuou uswonmm Hmuoe Houum uomuuoo manwmmom .coHUMOAMflmmmao wmouom mnmfieom mumo .NH mHQmB 76 as intelligible to the judges in their production of isolated vowel-bracketed plosives. The results of the Plosive Analysis Part B are opposed to studies which suggest that Parkinson subjects' production of isolated plosives are less intelligible than normals. Indeed, the results indicated that the Parkinson groups' production of isolated vowel-bracketed plosives were as intelligible as the age-matched controls to untrained judges. Therefore, one can conclude that the articulatory patterning necessary to produce the equally intelligible plosives must have been normal or "as normal" as the control groups production of'vowel-bracketed plosives. Three conclusions may be drawn regarding the results of Part B. First, one can conclude that the reported difficulty in the production of plosives by Parkinson Speakers is only true relative to ongoing speech and thus a result of impaired oral diadochokinesis. This conclusion would tend to support Hoberman's (1940) assumption that Parkinson subjects perform "normally" for isolated articu- latory movements. Second, one can conclude that the wide- spread use of anti-parkinson medication has improved the overall populations' production of plosives to the extent that they no longer differ from age-matched normals. This conclusion would be consistent with the observation that the anti-parkinson medication resulted in improved labial and other oral-muscular movements (Nakano et a1. 1973). 77 The third conclusion one can draw is that the age-matched control group, average age 72.5, is not representive of all normals in that they might also be deviant in their articulation of plosives. There is, however, no research indicating that an older population produces plosives differently from a younger population. Regardless of the reasons for the differences in con- clusions, these results indicate that the Parkinson sub- jects used in this study do not experience singular deficits in activation of isolated plosive gesture movements as measured by plosive intelligibility. CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary Parkinson's disease (parkinsonism) is a progressive, extrapyramidal system disorder generally thought to be asso- ciated with slow degeneration of certain basal ganglia and resulting from a decrease in concentration of dopamine, 'which is essential to the transmission of neural impulses. Symptoms of the disorder may develop at any age but most commonly occur in the fourth or fifth decade of life. Pro- gression of the symptoms may range over ten to twenty or more years. The disorder is characterized by muscular rigidity, tremor at rest, and impairment of voluntary move- ments. Approximately 2.5 million people in the United States suffer from this disorder. Among the symptoms of parkin- sonism are disturbance of speech which may include deviations of any of the five basic motor speech processes: respira- tion, phonation, resonance, articulation, and prosody. The subjects used in this study consisted of 12 patients, 6 male and 6 female, diagnosed by physicians as having Parkinson's disease. Each sex category was further subdivided into 3 subjects with severe symptoms and 3 sub- jects with mild symptoms. A group of 12 age and sex-matched 78 79 individuals was used as a control. The following phonetic materials were used in this study: 1) The Rainbow Passage, 2) the words from list C from the Multiple Choice Test of Intelligibility by Black (1963), 3) Cluster and CNC monosyllables, and 4) Isolated vowel-bracketed plosives. The distribution of articulatory pauses from the Rain- bow Passage for both the Parkinson group and the control group were compared statistically for differences in mean duration of the pauses. The pauses were detected and mea- sured by the instrument "pausimeter" (Tosi, 1965). The results of the statistical analysis indicated that the control subjects' mean duration of articulatory pauses were longer than the mean duration of the articulatory pauses for the Parkinson subjects. Spectrograms of the cluster and CNC samples were ob- tained to determine the mean frequencies of the first and second formants of the following vowels for both the Parkin- son group and the age-matched controls: /I/, /e/, /ae/, /a/, /A/, AD/, /o/. Euclidian distances from the control subjects' mean frequencies and the Parkinson subjects' mean frequencies were tested statistically for significance. The statistical analysis showed no significant differences among subjects of each subgroup, but significant differences among Parkinson and normals of corresponding subgroups were observed.‘ Although no interaction was observed across 80 the various subgroups, there was some homogeneity between vowel-sex-formant number-type of diagnosis with the amount and direction of the Parkinson groups' frequency deviations. Data on intelligibility of the Parkinson subjects was obtained by using the Black Test of Intelligibility (1963) and was compared with the normalized data provided with the test. The results of the intelligibility analysis suggest that Parkinson subjects diagnosed by their physicians as possessing either mild or severe involvement will have reduced intelligibility corresponding to the severity. The results also suggest that women with a severe diagnosis have better intelligibility than men with the same condition, and vice versa for subjects with a mild diagnosis. The perceptual features regarding plosive production were judged by a panel of untrained judges. The results indicated that judges perceive the isolated vowel-bracketed plosives as, in decending order of occurrence, a) other plosives, b) fricatives, c) nasals, and d) glides. However, the plosive analysis also indicated that the Parkinson groups'production of isolated plosives were as intelligible as an age-matched control group. The major conclusions regarding the plosive analysis are that 1) the Parkinson subjects' difficulty in the production of plosives reported in the literature is only true relative to ongoing speech, and/or 2) the widespread use of anti-parkinson medication has improved the overall pOpulations' production of plosives 81 to the extent that they no longer differ from age-matched normals. Conclusions Within the design of this study and the instrumenta- tion utilized, the following conclusions are appropriate: 1. Control subjects display longer articulatory pauses than do Parkinson subjects using the operational definition of a pause and the method of measurement intro- duced by Tosi (1965). Thus we can conclude that Parkinson patients speak at a more rapid rate when compared to normal individuals of the same age. 2. There is not a significant Euclidian difference between the mean frequency of the first and second formants of vowels uttered by Parkinson subjects within the same subgroup. There is a significant difference for the same vowels, as uttered by normal subjects and Parkinson~ subjects. The results suggest that Parkinson patients distort the first and second formants in monosyllables. 3. Parkinson subjects diagnosed by their physicians as possessing either mild or severe involvement will have reduced intelligibility corresponding to that diagnosis when measured by the Multiple Choice Intelligibility test by Black (1963). The results suggest that a medical diagnosis of severity will include intelligibility factors in that diagnosis. 4. Untrained judges perceive isolated vowel—bracketed 82 plosives uttered by Parkinson subjects as, in decending order of occurrence, other plosives, fricatives, nasals, and glides. 5. There is no significant difference between Parkin- son subjects and normals in their production of isolated vowel-bracketed plosives as determined by untrained judges. Thus, Parkinson individuals receiving anti—Parkinson medica- tion do not appear to experience difficulty producing iso- lated plosives. Recommendations Considering the findings of the present study, the following recommendations for future research are: l. A study should be conducted to determine how judges perceive the plosives produced by Parkinson subjects in ongoing speech. 2. A study should be conducted to determine whether there is a difference between the plosive intelligibility in ongoing speech by Parkinson subjects as compared to normals. 3. A study should be conducted to determine how hypo- kinetic dysarthria differs acoustically from Lehiste's (1965) results concerning general dysarthria. 4. A study should be conducted to compare the mean frequencies of the first and second formants in other types of dysarthria, especially flaccid dysarthria. 5. A study should be conducted to measure the mean pause duration of subjects displaying the acceleration 83 phenomenon. 6. A study should be conducted to determine whether articulation and voice therapy is effective in improving the overall intelligibility of Parkinson subjects. REFERENCES REFERENCES Almgren, P.C.; Andersson, A.L.; and Kullberg, G. Differences in verbally expressed cognition following left and right ventrolateral thalamotomy. Scand. J. Psychol., 10, 243-249 (1969). 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Motor disorders of the central nervous system and their significance to speech. J. Speech Hearing Dis. 2, 131-139 (1937). APPENDICES APPENDIX A THE RAINBOW PASSAGE When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. PeOple look, but no one ever finds it. When a man looks for something beyond his reach, his friends say he is looking for the pot of gold at the end of the rainbow. Throughout the centuries men have explained the rainbow in various ways. Some have accepted it as a miracle without physical explanation. To the Hebrews it was a token that there would be no more universal floods. The Greeks used to imagine that it was a sign from the gods to foretell war or heavy rain. The Norsemen considered the rainbow as a bridge over which the gods passed from earth to their home in the sky. Other men have tried to explain the phenomenon physically. Aristotle thought that the rainbow was caused by reflection of the sun's rays by the rain. Since then physi- cists have found that it is not reflection, but refraction by the raindrops which causes the rainbow. Many complicated ideas about the rainbow have been formed. The difference in the rainbow depends considerably upon the size of the water 93 94 drOps, and the width of the colored band increases as the size of the drops increases. The actual primary rainbow observed is said to be the effect of superposition of a number of bows. If the red of the second bow falls upon the green of the first, the result is to give a bow with an abnormally wide yellow band, since red and green lights when mixed form yellow. This is a very common type of bow, one showing mainly red and yellow, with little or no green or blue. APPENDIX B THE MULTIPLE CHOICE TEST OF INTELLIGIBILITY BY BLACK ———-—--- 1. Speaker I la. modernzfi rabbit glass crash (old 9 crab say forbade i pervacl {in} em:- u ed c ec -~ chin $1 drunk intent quench . 4 went waves . a ICC 0 v ' ’ wave visit way task query kind popular get I O 0 ap o-' ' burst Immense named commenc nave omena Errors 96 Correct. Speaker I la ....................... . ........ groove modern vice drew moderate fight crew modesty mice grew modest bite say forbade chink stay pervade kink stayed surveyed check spade survey chin stung drunk intent I stun- grunt intend 3 sun brunt content stunned runt intense quench busy wade went physics waves whence physic wave when visit way pass clearly fine I past weary find 5 cast quarry sign task query kind popular nurse set poplar first cap hopper birth guess opera burst guest immense named only commence name woman emit main pullman cement knave omen latter last swain ladder lash slain lattice laugh flame rabbit glass plain crash gold pail crab bowl poor craft cold ' polo crack bold palace 10. 11. 12. ARCH BANGS BARB BIND BLUSH BOLT BOUNCE BRONZE BUILT CATS CHAMP CHANT 96 APPENDIX C THE CLUSTER LIST 13. 14. 15. 16. 17. 18. 19. 20. CHARGE CLEARS CROWN CUTE DARK DROP DWARF ELSE 10. 11. 12. BAR BELL BUSH CHIN DAB DIP DIRGE FADE FAITH FOUR GAP GULL 97 APPENDIX D THE CNC LIST 13. 14. 15. 16. 17. 18. 19. 20. HEAD HOUSE HUT JAIL JOKE KERN KEG KID ATA ADA APA ITI IDI 98 APPENDIX E THE VOWEL-BRACKETED PLOSIVES 7. 10. 11. 12. IPI IBI UTU UDU UPU UBU 99 APPENDIX F PARKINSON SUBJECTS CNC LIST Mean Frequency of Each Formant Severity Sex Subject a e A as .) o I F 750 400 550 500 500 450 400 severe F A°F° F; 1500 2050 1000 2150 1050 1150 2100 F 750 400 450 400 600 450 100 severe F G'R' F; 1500 2000 750 650 1700 1150 1700 F 650 500 400 400 600 100 110 severe F L°W° F; 1200 2500 750 650 1200 600 550 . F 750 500 700 650 600 500 500 Mud F ”4"“ F; 1450 2000 1300 2000 1000 1150 2000 . F 700 500 650 600 600 500 500 Mild F 13°F“ F32" 1400 2000 1400 2250 1100 1200 2200 . F 700 550 750 650 500 500 500 mm F B'R° F; 1150 2650 1300 2350 850 1050 2750 Severe M C R F1 700 600 750 600 600 600 400 ' ' F2 1850 1300 1300 1350 1400 950 1250 S v r M C 0 F1 650 650 650 600 500 500 600 e e 3 ° ' F2 1400 2200 1400 1700 1000 1000 1300 Severe M J K F1 800 500 600 500 500 500 400 ' ' F? 1250 2050 1200 2100 850 1050 2000 . F 750 650 650 700 500 550 600 MM M B°S° F; 1200 1600 1050 1800 750 1000 1700 . F 600 500 600 700 500 500 450 M119 M F°B' F; 1000 2000 1400 1950 750 1250 2000 Mi 1d . M E . P . 550 450 550 500 450 450 500 £15” 1100 2150 1150 1800 700 1800 1550 100 APPENDIX G CONTROL SUBJECTS CNC LIST Mean Frequency of Each Formant Sex Subj ec t a e A ae 3 o I F I.(3 F1. 700 550 700 600 450 500 400 ° F2 1400 1600 1400 1650 800 1450 1150 F B (3 F1 750 600 750 750 750 500 700 ° F2 1400 2100 1700 2000 1100 1400 2200 F G (3 F1. 500 500 700 650 600 550 500 ' IF2 2100 2350 1500 2100 1000 1050 2300 F G E) F1, 500 650 550 700 500 500 500 ° ° F2 1400 1500 1350 1400 900 1200 1300 F Jflbd. F1 500 500 750 500 900 500 400 F2 1200 1500 1600 1700 900 1200 2200 F S S F 1 550 600 700 650 500 500 500 ' F2 1000 2500 1200 1600 900 1000 1100 M C F F 1 650 500 700 650 400 400 500 ° ° F2 1100 1900 2100 1800 650 700 1900 M R M F 1 700 500 700 600 500 500 450 ' ° F2 1200 2200 1550 1750 750 1700 2200 M W W F 1 700 450 650 500 400 500 400 ° F2 1150 1500 1300 1650 650 1400 1500 M J W F 1 700 400 600 500 450 500 400 ° ° F2 1200 2000 1400 1700 900 1000 1800 M L S F 1 500 500 700 600 500 450 450 ° F2 750 2300 1300 1050 800 1400 2100 M B B F 1 650 500 600 600 450 450 500 ° F 1250 1850 1300 1700 650 950 1600 101 APPENDIX H PARKINSON SUBJECTS CLUSTER LIST [Mean Frequency of Each Formant Severity Sex Subject a g A a D o I Severe F A'F ' 1F: 1333 2333 1333 2333 1333 333 2333 severe F G-F i; 1233 £33 £33 1333 1533 233 1333 severe F L~W- £23; 1383 £33 £33 2333 £33 233 £33 Mild F M £3; 13123 1233 1333 1333 £33 333 1333 Mild F B°F ' 3% 1333 2333 1533 2133 1333 1333 2333 Mild F B-F- 5; 1338 2333 1333 2333 333 333 2333 Severe M (3'1" 1:: 1333 1333 1333 1333 1333 333 1333 severe M C.D. S; 1823 1233 1233 1333 $33 333 1233 Severe M J '1“ 3% 1333 1333 1333 2333 1333 333 1333 Mild M FF 5; 1338 1333 13% 1333 338 333 1333 Mild M F-F- ‘5; 1333 1338 1233 1333 £33 323 1238 Mild M F-F- i; 1833 i230 i330 2333 383 333 1333 102 APPENDIX I CONTROL SUBJECTS CLUSTER LIST Mean Frequency of Each Formant Sex S ub j ec t a e A as 3 o I F 1;.G F1_ 750 600 700 600 600 500 500 F2 1300 2100 1500 2200 1000 800 2000 F B (3 F1 750 600 750 650 750 450 500 ' ' F2 1500 2100 1500 2200 1200 750 2200 F (3 C F]_ 800 550 700 700 650 600 600 ' ' F 2 1500 2500 1500 1500 1150 600 1700 F A D F 1 600 600 500 600 700 500 500 ' 1F2 .1150 2100 1500 1400 1400 900 1500 F J;rd F1 750 600 500 750 700 500 500 ° F2 1450 2100 1400 2000 1400 1050 1700 F S . S . F l 500 700 750 650 550 500 450 F2 1650 1700 1500 2500 1000 900 2500 M C F F l 700 600 600 650 550 350 500 ’ ' F 2 1100 1800 1150 1850 900 700 1800 M R M F l 600 600 550 550 600 400 450 ‘ ' IFZ 1250 1500 1400 2100 1000 650 2000 M W W F 1 500 550 500 500 400 450 450 ' ' 1F2 1250 1700 1300 1850 800 900 1600 M J W F 1 700 500 500 600 450 450 400 ° ' IF2 1300 1500 1500 1800 850 800 1800 M L S F 1 700 600 500 700 600 500 400 ' ’ 1F2 1500 2350 1400 1800 1000 850 1550 M B B F 1 600 600 600 550 500 500 350 ' ° ZFZ 1350 1500 1200 1850 1000 850 1700 Total Total 103 APPENDIX J PLOSIVE ANALYSIS OPEN RESPONSE SUBTEST FORM A Hafiz HMWMZ HmHmufl ~8qu muflaw mUHHU gflHflUflHh M>HH8HHM gHmOHm EUflgCD MPHMCHD EUHgCD 2 l l 3 l 12 122.3 HON-Hm...” 6.8-724. .2. H051 .. .._ 8 DDBBTDPBTDPB 8 TAPDTDPBTDPB 7 TDBBDBPBDDBB 7 TDPBTDPBTDPB 6 TDBBDBBBDDPB 6 TDPBTDPBTDPD d 5 DDBBDDPBTDPB d 5 TDPBTDPBTBPB 11... 1.. . .l M.“ 4. DDBBGDPBTDPB M A. TDPBTDPBDDPD e e 1 l m 3 DDBBGDBBTDPB m 3 TDTDTDPBDDPD ..N. 2 DDBBGDBBTDBB m 2 TDPBTDPBTDPB Bm Pm HM l DDBBDDBBGDPB EM 1 TDPBTDPPTBPB C C :I S AAAAIIIIUUUU ..I S AAAAIIIIUUUU TF u TDPBTDPBTDPB TF u TMPBTDPBTPPB CI 1 AAAAIIIIUUUU CI 1 A AAIIIIUUUU ES u ES U J8 m JS m BM .1 o c c o o c on a n a . BA .1 o u o o a o a o n u o o U t 1L9u1.4_brbwlnu9nua;9. U_L t 1;?.1.4.b,07/RV9AU1L2 SC S 111 SC S 111 104 APPENDIX K PLOSIVE ANALYSIS CLOSED-RESPONSE FORM B 1. ABA 2. ADA 3. ATA 4. APA ATA APA ADA ADA ADA ABA APA ATA APA ATA ABA ABA 5. ITI 6. IPI 7. IDI 8. ITI IDI IBI IBI IBI IBI IDI IPI IDI IPI ITI ITI IPI 9. UBU 10. UDU 11. UPU 12. UBU UPU UPU UDU UTU UDU UBU UTU UDU UTU UTU UBU UPU Subject Name Judge Name Percent Correct