ASSESSMENT OF COMMUNICATION ABILITIES IN MS

 
CONFERENCES
TOPIC: MULTIPLE SCLEROSIS

---

 
Abstract

Patients with Multiple Sclerosis often present motor, sensitive or cognitive impairments that interfere with their communicative abilities and also with their swallowing. According to recent literature, 25% of the PwMS present dysarthria, 40% dysphagia and between 40 and 70% cognitive impairment.
The main problem we do find when trying to demonstrate the role that speech therapy can play in fighting anyone of these symptoms is that we still lack of a consented screening battery to assess them.
Our objective is to define the material necessary to assess in a short and sensitive manner all these functions, including impairment, disability and handicap, in order to reflect the changes promoted by rehabilitation and to help us in redefining the objectives of our treatments.
Our purpose is to present a new screening battery for speech therapist based on a review of the assessment methods but also on the discussion of the different procedures used in the various MS Clinics that are working by now with MS patients in Europe.
This new battery includes different scales dedicated to: breathing, reflexes, sensitiveness, phonation, mobility, articulation, swallowing and neurolinguistical functions.
 

Communication disorders in MS may be caused by motor speech aspects (dysarthria), respiratory deficits, voice disorders (dysphonia), high-level language and cognitive function troubles (comprehension and expression). Although its rehabilitation in MS is still a relatively new phenomenon, it is becoming more common and beginning to be carried out systematically in many different European hospitals with particular regard to the motor aspects of speech (dysarthria).

In 1996, Ganty (Speech Therapy Department - National MS Centre - Melsbroek, Belgium) conducted a European survey to search for the place of speech therapy  (ST) in MS.
Of 25 questionnaires distributed to ST department, 11 were returned. Limited response may be due to the following:

A limited number of speech therapists work with MS patients

The ST is not systematically involved in the rehabilitation of MS patients

ST are either not interested in a collaboration or are unaware of or unfamiliar with this recent field of activity. The limited number of responses provide an idea of the organisation of treatment for MS patients

 
 In most institutions, the number of MS patients is a small proportion of the total population (10%). Only 2 of 11 centres provide services for primarily multiple sclerosis (>200 patients/year). 45% of MS patients received ST in 3 centres (50-100 patients/year). Only 5-10 % of MS patients received ST in 6 centres (10-50 patients/year).
 
 Assessment
 
 The most frequently utilised tests included
 

Dysarthria	Frenchay Dysarthria Assessment
	Robertson Dysarthria Profile
Swallowing	Screening Logeman
	Videofluoroscopy
Aphasia	Boston Diagnostic Aphasia Test
	Token Test

50% of institutions use the Functional Independence Measure (FIM)

Few tests are utilised for respiratory function, apraxia and voice disorders.

Assessment involves collaboration with external specialists:

ORL 7/11

Radiologist 5/11

Neurologist 2/11

Treatment

• Criteria for treatment are often based on medical indication
• In most cases speech therapy is not designed for all MS patients
• Individual treatment > group sessions
• Duration of single treatment: 20 ó 45 minutes
• Inpatients receive daily treatment
• Outpatients receive therapy once or twice a week

Speech therapy approaches

• 10/11 services provide advice to patients and family
• 7/11 services recommend and provide training with technical aids (communication & swallowing disorders)
• 7/11 services have an educational role
• 3/11 services visit patients in the home

Analytic-restorative approach

This approach consists of restoration of impairments, such as respiration, speech and swallowing. Almost 66% of the ST services treat impairments like dysarthria or dysphagia. The techniques used by the STY in various institutions are similar.
 

Aspect	Department (total: 11)	Advice ó Therapy
Respiratory dysfunction	1	Ventilation
		Oral motricity
Dysarthria	8	Rate control
		Compensation
Apraxia	7	Co-ordination
Voice disorders	8	Respiratory compensation
		Icing
Swallowing disorders	8	Postural control
		Feeding control
Language	9

Functional-compensatory approach

This approach consists of compensation for impairment.
 

Aspect	Department (total: 11)	Advice ó Therapy
Respiratory dysfunction	4	Postural advice
		Feeding
Swallowing disorders	7	Postural advises
		Diet
Cognitive deficits	5	Memory
Communication	7	Computers

 

Efficacy and expectations

The last part of the questionnaire focused on the efficacy regarding the strongest aspects of the ST department and which specific area is best developed. Dysarthria and swallowing are reported to be well developed in some institutions. Speech therapists wish to develop the management of swallowing, language and respiratory disorders, and, above all, to improve collaboration with other ST departments.
 

Efficacy	Swallowing	4/11
	Dysarthria	2/11
Expectations	Swallowing	3/11
	Language	3/11
	Respiration	3/11
	Co-operation	11/11

 

Conclusions

• ST treatment of MS was not systematic in Europe
• Assessment, collaboration with external specialists, group sessions and special techniques for treatment require further development
• Collaboration and further research are of great importance to improve the quality of ST departments in Europe.
• A comparative questionnaire will be sent in 2000.

Another inquiry realised by the ST Department of the National MS Centre of Melsbroek (Belgium) about communication and swallowing disorders in recently diagnosed MS patients has been send in 1998 to the attention of neurologists in Belgium and in France. Only 3% and 2% of neurologists answered respectively in Belgium and in France. We hypothesise that limited response may be due to the lack of education of physicians about MS.

HIGH-LEVEL LANGUAGE assessment and treatment in MS are still in their early stages and there is still little experience and literature regarding this. Until the nineties, literature didnít acknowledge the existence of high-level language impairment in MS patients. However, the first steps have already been taken, and this limited literature has already brought to light the presence of such impairments in individuals with MS, which is in agreement with the experiences of health staff involved in the care of these patients.

Traditionally, language problems have been linked mainly to cortical lesions. However, in recent years increasing attention has been paid to subcortical models of language processing (Alexander, Naeser, and Palumbo, 1987; Nadeau and Crosson, 1997; Wallesch and Papagno, 1988). The suggested subcortical lesion sites associated with language problems are the striato-capsular region, the thalamus and the basal ganglia. Some models suggest that language is subserved by a loop including both cortical and subcortical structures (Murdoch, 1997), and that these structures operate in an organised and co-ordinated fashion to produce and comprehend language (Crosson, 1985; Nadeau and Crosson, 1997). As multiple sclerosis affects subcortical areas, these models of subcortical language processing seem applicable in describing the aetiology of the language disorders seen in multiple sclerosis (Lethlean and Murdoch, 1997). One plausible explanation as to why some earlier studies have not found language deficits in multiple sclerosis is that these studies have used tools that are not sensitive enough to detect high-level language, but rather subtests of clinical aphasia examination batteries (Crosson, 1996; Lethlean and Murdoch, 1994).

Recent research has demonstrated the existence of high-level language dysfunction in multiple sclerosis (Lethlean and Murdoch, 1993; 1994; 1997). These studies showed that individuals with multiple sclerosis had difficulties understanding ambiguous sentences and metaphoric expressions, making inferences, and recreating sentences. They also exhibited poor performance on vocabulary and semantic tasks compared to control subjects.

Lethlean and Murdoch (1994) discuss naming errors in individuals with multiple sclerosis in detail in a study. They compared 60 individuals with multiple sclerosis and 60 matched controls on the type of naming errors. The multiple sclerosis groups made more naming errors than the controls, especially errors semantically related to the target word. Their conclusion was that the naming errors were not due to a perceptual deficit, but to a semantically based deficit, more specifically impaired access to semantic memory. Grossman, et al. (1995) have looked at sentence comprehension in multiple sclerosis. They used sentences varied in passive and active voice as well as in grammatical phrase structure. They found that a subgroup of the multiple sclerosis subjects exhibited impaired sentence comprehension and that these findings could not be fully explained by a global cognitive impairment or a dementia. Their conclusion was that there appears to be an association between reduced information processing speed and comprehension difficulties. Wallace and Holmes (1993) used the Arizona Battery for Communication Disorders in a study regarding cognitive-linguistic impairment in multiple sclerosis. They found that the multiple sclerosis group and the control group had similar results on 9 out of 15 subtests, but that on five linguistic subtests the multiple sclerosis group performed significantly worse. These subtests were object description, generative naming, concept definition, generative writing and picture description.

Current available data on the EFFICACY OF THE REHABILITATION OF COMMUNICATIVE ASPECTS IN MS is still quite poor. There is a lack of established treatment procedures and the progressive character of MS makes it difficult to define them. In such a situation, speech and language therapists plan and carry out treatment based mainly on their intuition (which is gained from his or her clinical experience). Very often, the therapist, the patient and the relatives notice an "improvement" but it is difficult to specify what the changes are and how they have been achieved. Thatís why we see the need for a universally accepted, manageable, efficient and short battery of assessment tests to be used in our daily clinical work. This would help us to optimise the rehabilitative treatment of the motor and cognitive impairments that causes communication disturbances in MS.

However, there is increasing evidence supporting the benefit of speech therapy for different groups of dysarthric speakers (for recent review of interventions suited for different dysarthria types, see e.g. McNeil, 1997; Yorkston, Beukelman, Strand, and Bell, 1999). However, so far extremely few studies have focused on improvement of speech in individuals with MS. Farmakides & Boone (1960), showed that 85% of the 68 treated patients improved their speech as a result of the speech training. The success of therapy was explained as a reduction of disuse atrophy in affected musculature. In addition, in a treatment study to investigate the use of visual feedback to enhance prosodic control, one of three subjects included had MS (Caligiuri and Murry, 1983). This subject not only showed improvements in speaking rate, prosodic control and a reduction in overall severity. He also demonstrated an improvement in articulatory precision, thought to be secondary to the gains associated with reduction in speaking rate and prosodic control. Successful speech treatment of individuals with MS was also reported by Hartelius, Wising, & Nord, 1997. This treatment focuses on a number of areas, including vocal efficiency (the production of relaxed and co-ordinated phonation), contrastive stress (in an effort to enhance linguistic prominence and reduce speech monotony), and verbal repairs (to improve production of an utterance that has been misunderstood).

The ASSESSMENT OF COMMUNICATION IN MS must give us information at different levels. According to the World Health Organisation (International classification of impairments, disabilities and handicaps - a manual of classification relating to the consequences of disease. Geneva, Switzerland: WHO, 1980), three levels of consequences of disease can be described:

• Impairments are abnormalities of structure or functions of organs, for example decreased muscle strength.
• Disability is experienced by a person as functional limitations, for example decreased morbidity or communication.
• Handicap applies to the social consequences of disease and the disadvantages person experiences as a result of the disease.

Thus, first of all the assessment has to allow us to establish which is or are the impairment or impairments that causes the communication disturbance (for example, severe hypotonicity in the respiratory muscles which gets worse with fatigue and moderate dyscoordination of the orofacial movements). Secondly, it will be necessary to observe what consequences (disabilities) are triggered by the impaired functions (for example, speech monotony, speech fatigue, slowdown of speech rate, etc.). Third, it will be necessary to find out how and how much these impairments and disabilities are interfering with the personís communication and causing changes in his or her daily life (degree of handicap). In this way, assessment will provide us with useful information that will allow us to establish the right rehabilitation goals (based on the personal, semiological and evolutionary features of the patient and his/her disease). Secondly, we will be able to carry out an appropriate follow-up of the changes produced in a patientís communicative disturbances and to take the necessary measures at the right moment. Thirdly, we will be able to compare the development between different patients using different rehabilitation methods or the comparison with cases in which no rehabilitation is provided.

If we begin focusing on DYSARTHRIA (a speech disturbance caused by motor or sensory impairment), the first thing to do would be to appropriately assess mobility, sensitivity and reflexes of the muscular groups involved in the production of speech (respiratory, phonatory, resonatory and articulatory). The assessment of mobility includes muscular tone and strength and movement amplitude, rate and co-ordination. If such impairments are present, there may be aspects of the personís speech that will appear to the listener as at least "abnormal", or "unusual" or even unintelligible in severe cases. If the impairment is mild, it is also possible that the patient will notice a change in his/her speech without the listener noticing it.

There are a few tests which are used in the assessment of impairment and disability in dysarthria. A few available dysarthria tests in English focus on different aspects of the motor speech disorder (Robertson, 1982, Enderby, 1983). There is also an equivalent test in Swedish (Hartelius & Svensson, 1990). You can also find tests on intelligibility at the references.

Almost all the tests are based on observation and evaluation of the patientís speech by the examiner. Consequently, they are basically subjective. Although some of the items have standard values that give an approximate idea of the normality ranges (such as duration of the maintenance of the air in exhalation, both voiceless and with voice, amount of diadochokinetical orofacial movements in a certain time, amount of syllables spoken in one second, etc.). To get more objective data it is necessary to use specific techniques that require special devices.

The obvious goal of human communication is understanding. Reduced speech intelligibility can be caused by a number of different speech impairments, including neurogenic speech disorders such as dysarthria. Over several decades, dysarthria has been the object of perceptual and instrumental investigations, with focus primarily on dysarthria as an impairment, a deficit in the musculature of respiration, phonation, and oral motor performance of the dysarthric speaker. In the last 15 years, however, increased attention has been given to dysarthria as a disability, with focus more on the success of communication, that is, to what extent the speech impairment affects the intelligibility of the speaker. Consequently, in measuring decreased intelligibility caused by dysarthria we do not primarily focus attention on the speech impairment within the dysarthric speaker, but rather on the effect the impairment (together with any compensatory strategies performed by the individual) has on the process of comprehension within the listener. Reduced intelligibility can thus be used as an index of severity of speech disorder and as a functional measure of disability and used in monitoring disease progression or treatment effects. The theoretical basis of intelligibility in speech disorders as well as questions of measurement and management are covered in Kent (7) and in Yorkston, Beukelman, & Bell (19). Several test procedures intended for dysarthric populations have been developed and are being explored by research groups around the world.

Intelligibility can be defined as "the degree to which the speaker's intended message is recovered by the listener" (9, p. 483). Several studies point to the conclusion that articulatory precision of segments (consonants and vowels) are more strongly correlated to speech intelligibility than suprasegmental features such as duration, stress, intonation (for a review see 14). There are basically two different methods of quantifying the degree of match or mismatch between intended and perceived messages and these are compared by Schiavetti (12). The different methods are: 1) word identification tests in which the listener is required to write down the perceived words or sentences and 2) scaling procedures in which the listener estimates or rates the intelligibility of the speaker, using an equal appearing interval scaling procedure or direct magnitude estimation. Schiavetti recommends the use of word identification tests and argues that neither interval scaling nor percentage estimation judgements of speech intelligibility have proven to be valid, reliable, and practical techniques for measurement of speech intelligibility.

Intelligibility is influenced by several factors, including the speaker (degree of speech impairment) and the speech task (words or sentences). The latter factor also interacts with the degree of speech impairment in that severely dysarthric individuals are more intelligible in single words than in sentences, while the opposite is true for mildly dysarthric individuals (15). Intelligibility is also affected by the transmission system (live or tape-recording) and characteristics of the listener (judges' familiarity with dysarthric speech as well as with the speech material being tested tend to increase intelligibility, 1, 13, 16, 17). Finally, intelligibility is also influenced by the listening task (forced-choice word selection generating higher intelligibility scores than orthographic transcription). All these factors have to be considered in an intelligibility measurement procedure.

The concept of intelligibility has also been further expanded to include speech signal-independent information such as semantics, syntax, gestures, orthographic cues and physical context. The concept is thereby referred to as comprehensibility, that is the adequacy of speech performance in a social context (20). Both semantic and syntactic cues have been shown to improve the sentence intelligibility of severely but not moderately involved dysarthric speakers (2). The reason for this is that the latter category is already fairly understandable. These cues are not beneficial to profoundly dysarthric speakers either (5), presumably because they are beyond the level of speech impairment where intelligibility can be improved with contextual cues.

As mentioned above, several tests of intelligibility of dysarthric speech have been developed, and their different features are outlined in Table 1. Four of these tests have word parts that allow both quantitative and qualitative analyses. These are Kent, et al.'s Word test (9), the German Munich Intelligibility Profile (21, 22) and the Danish Test af Fonetisk Forståelighed (11). These tests are in the form of rhyme tests, which means that they are constructed from minimal pairs (that is two words that differ in one phonetic contrast) representing articulatory difficulties often found in dysarthric speech. The answering format of a rhyme test is multiple choice. Each word on the answering sheet forms a minimal pair with the target word. By analysing the judges' misperceptions, a qualitative measure is obtained. The sentence intelligibility assessments included in the tests differ. The Frenchay Dysarthria Assessment (4) uses different words presented in a carrier phrase. This means that it is really an additional test of word intelligibility, with the difference that the word is pronounced within a sentence, which might require extra effort on the part of the speaker. The sentence itself does not, however, add any contextual cues to aid the intelligibility. The Assessment of Intelligibility of Dysarthric Speech (18) includes a pool of general sentences, randomly selected. Consequently, these sentences have a certain amount of contextual predictability. The ideal assessment of sentence intelligibility would be one where an infinite number of normal sentences could be randomly generated from extensive word or sentence pools, and where the semantic context didn't make the sentences too predictable.The semantic unpredictability makes the test even more sensitive to milder impairments. Theoretically, the influence of syntax (which also adds a certain amount of predictability) could also be excluded, by using randomly collected sequences of words presented as a sentence ("scrambled speech"). However, the status of these sequences of words as sentences could be questioned.

In summary, an intelligibility test of dysarthric speech needs to:

1) provide a quantitative severity index as well as qualitative, explanatory information concerning affected speech segments,

2) include words as well as sentences, and both word selection and transcription procedures, in order to capture the decreased intelligibility of both mildly and severely dysarthric speakers,

3) be able to produce completely new, but equivalent lists of words and sentences, in order to avoid judge familiarisation with the speech material and facilitate the use of only one judge, and

4) be language specific.

Focusing now on the HIGH-LEVEL LANGUAGE FUNCTIONS ASSESSMENT, valuation of impairment will consist on the evaluation of those cognitive functions that are involved in the use of language. That means that it will be necessary to take into account both production and reception of language and both oral and written forms (speaking, listening, writing and reading). Attentional, executive and some memory functions do play a very important roll in these processes. Current research is investigating weather or not specific linguistic functions might be impaired in MS and in other diseases with a subcortical cognitive impairment pattern.

As we said in the beginning, high-level language functions as a specific domain is a very new topic in MS rehabilitation. Test batteries trying to cover various high-level language functions differ, but should include the following types of items: repetition of long sentences, comprehension of logico-grammatical sentences, naming, comprehension of ambiguous sentences, comprehension of metaphors, word fluency, recreating sentences and making inferences (Laakso, Brunnegård, Ahlsén, & Hartelius. 1999).

So aphasia test batteries are not suitable in the assessment of these patients. That is why there is still a lack of specific test batteries to assess it. However, some new material has been produced recently and more is being currently developed.

For example, within a research project on cognitive stimulation, which is currently running in the Hospital de Dia de la Fundació Esclerosi Múltiple in Barcelona, a test battery for language assessment of MS patients has been developed and is being used. This scale was created in the Escola de Patologia del Llenguatge de líHospital de la Santa Creu i Sant Pau (Barcelona),. It is partially computerised and includes four tests: Naming, Written sentences comprehension, Orally presented sentences comprehension and Oral expression. (Contact: Marta Renom- epl.lab@cbi.es)

It should also be taken into account that the border between dysarthria and high level language functioning is not always that clear. Cognitive, proprioceptive, motor and sensory impairment, sometimes appear as inseparable. Let us take as an example a patient with difficulties to initiate speech, control speech rate, and dysprosody. Both dysarthria and a frontal lobe syndrome with dysexecutive functioning could lead to such a speech disturbance. Adequate and open-minded assessment is required in order to understand fully the nature of the disturbance and be able to provide adequate rehabilitation.

An approach to a cerebral lesion that causes dysarthria which limits its assessment and treatment to the motor aspects of speech would be insufficient. The possible existence of cognitive or emotional disturbances following the same brain lesion must not be forgotten. Its presence will interfere with all activities of daily living and with almost every rehabilitative procedure. Furthermore it can have consequences on the patientís self-esteem, that again can interfere with the course of rehabilitation.

In the assessment and rehabilitation of dysarthria, the existence of cognitive impairment will have to be taken into account at every stage of rehabilitation:

a) When doing assessment. It might sometimes be very difficult to establish where the exact limits are between the motor or cognitive nature of some impaired speech features (lack of verbal initiative, hesitancies, prosody or speech rate disturbances, etc.).

b) When deciding which aspects have to be assessed and how. Which aspects of the cognitive functions are relevant when planning the treatment of dysarthria? Is it necessary to take into account the cognitive impairment of the patient when assessing dysarthria?.

c) When defining the rehabilitation goals. There are goals which could be achieved in patients with dysarthria but without cognitive impairment that are unattainable if there is cognitive impairment (such as impairment of learning, abstraction, anticipating and planning abilities, difficulties to maintain attention for a certain period of time, lack of motivation, impulsivity or apathy).

d) When defining the intervention method. With a patient with the above defined cognitive or emotional and motivational impairments it is necessary to provide dysarthria rehabilitation using some of the principles of cognitive rehabilitation (such as a sequence of steps within a certain procedure, the verbalisation of every step, the use of cognitive strategies or external aids to make it easier to incorporate the advice or taught techniques, etc.). On the other hand, if group rehabilitation is provided, it will be important to take these aspects into account when making groups so that they are as homogeneous as possible regarding the degree and nature of cognitive impairment.
 
 

An appropriate rehabilitation of dysarthria can therefore require the participation of specialists in neuropsychology who assess patientís cognitive impairment and its consequences to provide the necessary information to establish an adequate rehabilitation plan. To summarise, in patient with cognitive impairment, the success of rehabilitation will only be possible if all the members of the health staff are completely familiar with and take into account neuropsychological impairment (which is often not apparent to the eye!) when establishing rehabilitation goals and methods.

In evaluating the effects of speech intervention in dysarthric patients, it is of great importance to consider not only the outcome measures reflecting the speech impairment (such as maximum sustained phonation, fundamental frequency variability, etc.). It is as important to consider the more global aspects reflecting disability and handicap (such as intelligibility, comprehensibility, and communicative competence). This is especially true in groups with progressive neurological conditions who are faced with increasing impairment. In these patient groups an increasing or even a stable disability or handicap level as an effect of therapy would indicate a treatment effect.

As we get to the point of assessing the HANDICAP (caused by both dysarthria and/or by high-level language impairment) the roll of subjectivity increases. We spoke above about how patientís speech seemed to him/herself or to the listener. This subjectivity has to be taken into account in the assessment. On the one side, the perception of the patientís speech and language and of the changes produced in them as time goes by can differ significantly between the patientís, their relatives, their social environment and the health staff. On the other hand, the same impairment and disability in two patients can interfere in very different ways and degrees with their lives, depending on their age, job, personality, family situation, etc. Therefore it will be useful to have information about the patientís communication in daily life and about the possible changes in patientís life caused by MS in general and more specifically by the speech or language impairment. Information on the amount and variety of his speaking partners and conversational topics, on his/her verbal initiative, on how he/she thinks that his/her speech and language are (that can go from exaggerated worry to the total oblivion) and how he/she feels that the attitude of other people towards his/her speech is; how context or emotional factors influence his communication (noise, nervousness); if there is an attitude of avoiding communication; if he/she has developed compensatory strategies, etc.

Yorkston & Bombardier have developed the questionnaire: "The Communication Profile for Speakers with Motor Speech Disorders" (Yorkston & Bombardier, 1992) including 100 items divided into statements involving:

1. Situational difficulties, e.g. "It is difficult for me when I am ordering food or drinks at a restaurant."

2. Compensatory strategies, e.g. "If my listener does not understand, I try to repeat more clearly."

3. Speech characteristics, e.g. "My speech is sometimes too loud or too soft." (negative characteristic) and "I am skilled at handling difficult speaking situations." (positive characteristic).

4. Perceived reactions of others, e.g. "People tend to get impatient because I speak slowly."

The dysarthric speaker is to decide to what degree (ranging from "Strongly agree - Agree - Neutral - Disagree - Strongly disagree, or Not applicable) he or she agrees with the particular statements. The questionnaire was initially used to describe the perceived difficulties of 33 speakers with different degrees and types of dysarthria (Yorkston, Bombardier & Hammen, 1994). It has also been used to document the perceived disability of 15 patients with Parkinson's disease and their spouses (Antonius, Beukelman & Reid, 1996) and to document maintenance of speech changes in six participants in a Parkinson's disease speech treatment group (Sullivan, Brune & Beukelman, 1996).

A questionnaire on daily life aspects of communication has been developed in the Escola de Patologia de Llenguatge (EPL) de líHospital de la Santa Creu i Sant Pau (Barcelona). It is being used currently in a research project on cognitive stimulation in patients with MS, carried out currently in Hospital de Dia de la Fundació Esclerosi Múltiple (Barcelona) and in the daily clinical work with aphasical patients in the EPL. It includes 5 blocs on: (1) Changes produced in patientís life since beginning of the communicative disturbances; (2) Verbal initiative; (3) Oral comprehension; (4) Written comprehension; (5) Attitude: Personal experience of his/her communication, presence of interfering context factors; presence of attitude of avoiding communication and presence of compensatory strategies (Contact address: Marta Renom- epl.lab@cbi.es)

Obviously, it is not possible to define a universal test battery to assess communication problems in MS. In each case and in each circumstance it will be necessary to decide which is the most appropriate way to carry out assessment. In certain cases and in certain rehabilitation circumstances it will be necessary to assess impairment exhaustively and as objectively as possible. That will permit precise control of the effect of a specific rehabilitation method systematically administered or to make a precise follow-up of the impairment.

In other cases, the rehabilitation goals can be directed more at improvement of disability and handicap. This can be appropriate if the degree of impairment is severe and also taking into account many other factors. In these cases, the main aim of therapy might be to reduce disability and handicap, increasing patientís metacognition and self-control of his/her disability, providing strategies (teaching techniques, giving advice, suggesting cognitive tips, etc.) or training in the use of external aids (such as a communicator, a notebook, etc.). In these cases it will be much more important to go into the assessment of disability and handicap deeper, within a wider vision of the patient as a "whole" person. Therefore assessment should logically be adjusted to the goals of rehabilitation.

In conclusion, we would like to highlight that the above suggested assessment of communication in MS is based on a very clinical point of view that assumes that assessment and rehabilitation have the same aim, within a global approach to the patient by an interdisciplinary team. The speech and language assessment presented above should be completed with information regarding other aspects of the disease (neurological, social, emotional related to the independence of the patient in different activities of daily life, etc.). With this in mind, the above suggested assessment is not based on taxonomic classifications but tries to define in a clear manner the different parameters involved in communication on an impairment, disability and handicap level (motor, sensory and cognitive impairment, together with information about his/her daily living activities and with the emotional, family, social and work situation) and understand the way how they all interact with each other.
 
 

REFERENCES

1- Literature references on high-level language functions in MS.

Alexander, M.P., Naeser, M.A., and Palumbo, C.L., 1987, Correlations of subcortical CT lesion sites and aphasia profiles. Brain, 110, 961-991.

Crosson, B., 1985, Subcortical functions in language: A working model. Brain and Language, 25, 257-292.

Crosson, B., 1996, Assessment of subtle language deficits in neuropsychological batteries: Strategies and implications. In: R.J. Sburdone & C.J. Long CJ (eds) Ecological validity of neuropsychological testing, (Delray, FL: GR Press/St Lucie press Inc.), pp. 243-259.

Grossman, M., Robinson, K.M., Onishi, K., Thompson, H., Cohen, J., and Désposito, M., 1995, Sentence comprehension in multiple sclerosis. Acta Neurologica Scandinavica, 92, 324-331.

Lethlean, J.B. and Murdoch, B.E., 1993, Language problems in multiple sclerosis. Journal of medical speech-language pathology, 1(1), 47-59.

Lethlean, J.B. and Murdoch, B.E., 1994, Naming errors in multiple sclerosis: support for a combined semantic/perceptual deficit. Journal of Neurolinguistics, 8(3), 207-223.

Lethlean, J.B. and Murdoch, B.E., 1997, Performance of subjects with multiple sclerosis on test of high-level language. Aphasiology, 11, 39-57.

Murdoch, B.E., 1997, Subcortical mechanisms in language impairment. Presentation at the American Speech and Hearing Association (ASHA) Conference, Nov 20-23, Boston MA.

Nadeau, S.E. and Crosson, B., 1997a, Subcortical aphasia. Brain and Language, 58, 355-402.

Nadeau, S.E. and Crosson, B., 1997b, Reply. Brain and Language, 58, 355-402.

Wallace, G.L. and Holmes, S., 1993, Cognitive-linguistic assessment of individuals with multiple sclerosis. Archives of Physical and Medical Rehabilitation, 74, 637-643.

Wallesch, C.W. and Papagno, C., 1988, Subcortical Aphasia. In: F.C. Rose, R. Whurr, and M.A. Wyke, M.A. (eds), Aphasia, (London: Whurr Publishers), pp. 256-287.

 

 

2- Literature references on high-level language functions and dysarthria rehabilitation in MS or in general.
 

Caligiuri, M.P. & Murry, T. (1983). The use of visual feedback to enhance prosodic control in dysarthria. In W.R. Berry (Ed.), Clinical dysarthria (pp. 267-282). San Diego: College-Hill Press.

Farmakides, M.N. & Boone, D.R. (1960). Speech problems of patients with multiple sclerosis. Journal of Speech and Hearing Disorders, 25, 385-390.

Hartelius, L., Wising, C., & Nord, L. (1997). Speech modification in dysarthria associated with multiple sclerosis: An intervention based on vocal efficiency, contrastive stress, and verbal repair strategies. Journal of Medical Speech-Language Pathology, 5(2), 113-140.

Malcolm R. McNeil (Ed.): Clinical Management of Sensorimotor Speech Disorders. New York: Thieme Medical Publishers, 1997

Kathryn M. Yorkston, David R. Beukelman, Edythe A. Strand & Kathleen R. Bell: Management of Motor Speech Disorders in Children and Adults. Austin: Pro-Ed Inc., 1999.

3- Literature references on intelligibility

Beukelman, D.R. & Yorkston, K.M. (1980). The influence of passage familiarity on intelligibility estimates of dysarthric speech. Journal of Communication Disorders, 13, 33-41.

Carter, C.R., Yorkston, K.M., Strand, E.A., & Hammen, V.L. (1996). Effects of semantic and syntactic context on actual and estimated sentence intelligibility of dysarthric speakers. In: D.A. Robin, K.M. Yorkston, & D.R. Beukelman (Eds.) Disorders of motor speech: Assessment, treatment, and clinical characterisation. Baltimore: Paul H: Brookes Publishing Co.

Elert, C.C. (1989). Allmän och svensk fonetik. Stockholm: Norstedts förlag AB.

Enderby, P. M. (1983). Frenchay Dysarthria Assessment. San Diego, CA: College-Hill Press.

Hammen, Yorkston, K.M., & Dowden, P. (1991). Index of contextual intelligibility. In C.A. Moore, K.M. Yorkston, & D.R. Beukelman (Eds.) Dysarthria and apraxia of speech. Baltimore: Paul H. Brookes Publishing Company.

Hartelius, L. & Svensson, P. (1990). Dysartritest. Stockholm: Psykologiförlaget.

Kent, R.D. (Ed.) (1992). Intelligibility in speech disorders: Theory, measurement, and management. Amsterdam: John Benjamins Publishing Co.

Kent, R.D., Kent, J.F., Weismer, G., Sufit, R.L., Rosenbek, J.C., Martin, R.E., & Brooks, B.R. (1990). Impairment of speech intelligibility in men with amyotrophic lateral sclerosis. Journal of Speech and Hearing Disorders, 55, 721-728.

Kent, R.D., Weismer, G., Kent, J.F., & Rosenbek, J.C. (1989). Toward phonetic intelligibility testing in dysarthria. Journal of Speech and Hearing Disorders, 54, 42-499.

Petersen, E.F. (1997a). Phonetic intelligibility testing in dysarthria. Validity and reliability of listeners' perceptions. Logopedics Phoniatric Vocology, 22, 105-117.

Petersen, E.F. (1997b). Test af Fonetisk Forståelighed. Valby, Denmark: INHAKO.

Schiavetti, N. (1992). Scaling procedures for the measurement of speech intelligibility. In: R.D. Kent (Ed.) Intelligibility in speech disorders: Theory, measurement, and management. Amsterdam: John Benjamins Publishing Co.

Tjaden, K.K. & Liss, J.M. (1995). The role of listener familiarity in the perception of dysarthric speech. Clinical Linguistics & Phonetics, 9(2), 130-154.

Weismer, G. & Martin, R.E. (1992). Acoustic and perceptual approaches to the study of intelligibility. In: R.D. Kent (Ed.) Intelligibility in speech disorders: Theory, measurement, and management. Amsterdam: John Benjamins Publishing Co.

Yorkston, K.M. & Beukelman, D.R. (1978). A comparison of techniques for measuring intelligibility of dysarthric speech. Journal of Communication Disorders, 11, 499-512.

Yorkston, K.M. & Beukelman, D.R. (1980). A clinician-judged technique for quantifying dysarthric speech based on single word intelligibility. Journal of Communication Disorders, 13, 15-31.

Yorkston, K.M. & Beukelman, D.R. (1983). The influence of judge familiarisation with the speaker on dysarthric speech intelligibility. In: W. Berry (Ed.) Clinical Dysarthria. Boston, MA: College-Hill Press.

Yorkston, K.M. & Beukelman, D.R. (1984). Assessment of intelligibility of dysarthric speech. Tigard, Oregon: CC Publications.

Yorkston, K.M., Beukelman, D.R., & Bell, K.R. (1988). Clinical management of dysarthric speakers. Boston: College-Hill Press.

Yorkston, K.M., Strand, E.A., & Kennedy, M.R.T. (1996). Comprehensibility of dysarthric speech: Implications for assessment and treatment planning. American Journal of Speech-Language Pathology, 5, 55-66.

Ziegler, W., Hartmann, E., & von Cramon, D. (1988). Word identification testing in the diagnostic evaluation of dysarthric speech. Clinical Linguistics & Phonetics, 2(4), 291-308.

Ziegler, W., Hartmann, E., & Wiesner, I. (1992). Dysarthriediagnostik mit dem "Münchner Verständlichkeits-Profil" (MVP) ó Konstruktion des Verfahrens und Anwendungen. Nervenarzt, 63, 602-608.

 

 

4- References on dysarthria scales
 

Enderby, P.M. (1983). Frenchay dysarthria assessment. San Diego, CA: College-Hill Press.

Hartelius, L. & Svensson, P. (1990). Dysartritest. Stockholm: Psykologiförlaget.

Hartelius, L., Svensson, P., & Bubach, A. (1993). Clinical assessment of dysarthria: Performance on a dysarthria test by normal adult subjects, and by individuals with Parkinsonís disease or with multiple sclerosis. Scandinavian Journal of Logopedics and Phoniatrics, 18, 131-141.

Robertson, S.J. (1982). Dysarthria profile. S.J. Robertson, Manchester Polytechnic.

 

 

5- References on neuropsychological and neurolinguistical impairment in MS
 

Laakso, K., Brunnegård, K., Ahlsén, E., & Hartelius, L. (1999). Assessing high-level language in individuals with multiples sclerosis: A pilot study. Manuscript accepted for publication in Clinical Linguistics and Phonetics.

6- References on Yorkston Scale and other scales
 

Yorkston, K.M. & Bombardier, C. (1992). The Communication Profile for Speakers with Motor Speech Disorders. Unpublished questionnaire, University of Washington, Seattle.

Yorkston, K.M., Bombardier, C., & Hammen (1994). Dysarthria from the viewpoint of individuals with dysarthria. I: Till, J.A., Yorkston, K.M., & Beukelman, D.R. (Eds.) Motor speech disorders: Advances in assessment and treatment. Baltimore, MS: Paul H. Brookes Publishing Co.

Antonius, K. Beukelman, D.R., & Reid, R. (1996). Communication disability of Parkinson's disease: Perceptions of dysarthric speakers and their primary communication partners. I: Robin, D.A., Yorkston, K.M., & Beukelman, D.R. (Eds.) Disorders of motor speech; Assessment, treatment, and clinical characteristics. Baltimore, MD: Paul H. Brookes Publishing Co.

Sullivan, M.D., Brune, P.J., & Beukelman, D.R. (1996). Maintenance of speech changes following group treatment for hypokinetic dysarthria of Parkinson's disease. I: Robin, D.A., Yorkston, K.M., & Beukelman, D.R. (Eds.) Disorders of motor speech; Assessment, treatment, and clinical characteristics. Baltimore, MD: Paul H. Brookes Publishing Co.

---