Facilitators, barriers, and strategies of communication in Malaysian school-age children with non-syndromic cleft lip and palate: Results of in-depth online qualitative interviews.

This study explores the perceptions of facilitators, barriers to communication and strategies in Malaysian school-aged children with non-syndromic cleft lip and palate (CL/P), parents, and teachers. Fourteen children with non-syndromic CL/P aged 7 to 12 years, their parents (n = 16), and their teachers (n = 10) were recruited via purposive sampling. Participants were selected based on resilience scores (RS-10; (Wagnild, 2015) distinguishing low (<34) from high resilience (35-40) (Wagnild, 2015). Individual in-depth interviews were conducted online and evaluated qualitatively. The analyses were conducted utilising the guidelines by Braun and Clarke (2006). Inductive thematic analysis was performed. Facilitators for communication identified by children, parents and teachers were the child's personal attributes, common interests, and helping others. Barriers that were identified were unfamiliar conversation partners, and insensitive comments or questions. Children used passive (e.g. ignored) and active (e.g. retorted, explained the condition) strategies to address social communication issues. Children with high resilience responded more actively than children with low resilience. Strategies that were described by the parents included accepting the child, empowering themselves, following the cleft management plan, and empowering the child. Teachers adopted general approaches such as giving encouragement, increasing confidence, and teaching empathy. The presence of face masks was perceived as both a facilitator and a barrier to communication. The study provides information on challenges encountered and coping mechanisms used by children with non-syndromic CL/P, their parents and their teachers. This knowledge may help the development of targeted interventions to support the communication of children with non-syndromic CL/P in school.

Telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER): A pilot study for patients treated with surgery for oral cavity carcinoma.

BACKGROUND: To address the rehabilitative barriers to frequency and precision of care, we conducted a pilot study of a biofeedback electropalatography (EPG) device paired with telemedicine for patients who underwent primary surgery +/- adjuvant radiation for oral cavity carcinoma. We hypothesized that lingual optimization followed by telemedicine-enabled biofeedback electropalatography rehabilitation (TEBER) would further improve speech and swallowing outcomes after "standard-of-care" SOC rehabilitation. METHOD: Pilot prospective 8-week (TEBER) program following 8 weeks of (SOC) rehabilitation. RESULTS: Twenty-seven patients were included and 11 completed the protocol. When examining the benefit of TEBER independent of standard of care, "range-of-liquids" improved by +0.36 [95% CI, 0.02-0.70, p = 0.05] and "range-of-solids" improved by +0.73 [95% CI, 0.12-1.34, p = 0.03]. There was a positive trend toward better oral cavity obliteration; residual volume decreased by -1.2 [95% CI, -2.45 to 0.053, p = 0.06], and "nutritional-mode" increased by +0.55 [95% CI, -0.15 to 1.24, p = 0.08]. CONCLUSION: This pilot suggests that TEBER bolsters oral rehabilitation after 8 weeks of SOC lingual range of motion.

Differences in nasalance scores obtained with different Nasometer headsets.

The goal of the present research study was to investigate possible differences in nasalance scores between different Nasometer headgears. Frequency response characteristics of microphone pairs in a Nasometer model 6200, a model 6450 and two model 6500 headsets were compared using long-term average spectra of white noise and multi-speaker babble signals. Prerecorded sound files from a male and a female speaker were used to record nasalance scores with the four Nasometer headsets and to calculate cumulative absolute differences within and between the headsets. The main outcome measures were the cumulative absolute differences between the decibel (dB) values in the frequency bins from 300 to 750 Hz for the nasal and oral channels of each microphone pair. Cumulative absolute differences between nasalance scores of repeated stimuli within and across Nasometer headsets were tabulated. Results showed that cumulative absolute differences for the frequency range 300-750 Hz were between 6.58 and 7.68 dB. Within headsets, 95.6% to 100% of measurements of all four Nasometer headsets were within 3 nasalance points, although test-retest differences of up to 6 nasalance points were found. Between headsets, 56.1% to 98.9% of measurements were within 3 nasalance points, with the single largest difference of 8 nasalance points. In conclusion, differences between repeated nasalance scores obtained with the same and different headsets were noted. Clinicians should allow a margin of error of ±6 to 8 nasalance points when interpreting scores from different Nasometer headsets.

The Role of Instructions in Motor Learning of Oral Versus Nasalized Speech Targets.

PURPOSE: The purpose of this study was to investigate how general, implicit instructions with auditory-perceptual emphasis; specific, explicit instructions with biomechanical focus; or both affect learning of oral-nasal balance control in speech. METHOD: Thirty healthy, vocally untrained participants were assigned to one of three instructional groups (i.e., implicit, explicit, and integrated) and learned to produce oral versus nasalized vowel-, syllable-, and phrase-level targets during once-weekly sessions over 4 weeks. Learning gains and performance variability were analyzed using nasometry. RESULTS: We observed a significant main effect of instruction type on learning gains at phrase level (p = .016). Specifically, the integrated group (M = 59.8%) significantly outperformed the explicit group (M = 37.9%) and numerically outperformed the implicit group (M = 45.1%). For nasalized phrase targets, results revealed a significant main effect of instruction type on performance variability (p = .042), but pairwise comparisons between instruction groups were not significant. CONCLUSIONS: The integration of implicit processes via auditory-perceptual modeling and explicit processes via relevant biomechanical directives resulted in larger motor learning gains, especially at higher levels of task complexity (i.e., phrase) compared to providing implicit or explicit instruction alone. The higher performance variability (i.e., less stable productions) that was sometimes induced by explicit instruction did not negatively impact learning when integrated with implicit instruction. Clinical implications for speech/voice therapy models are discussed.

The Impact of Fan-Type Rapid Palatal Expanders on Speech in Patients With Unilateral Cleft Lip and Palate.

Rapid palatal expanders (RPEs) are commonly used in patients with cleft lip and palate (CLP) prior to secondary alveolar bone grafting (SABG). Their position and size can impede tongue movement and affect speech. This study assessed changes in perception and production of speech over the course of RPE treatment.Prospective longitudinal.Tertiary university-affiliated hospital.Twenty-five patients with unilateral CLP treated with Fan-type RPEs, and their parents.Patient and parent speech questionnaires and patient speech recordings were collected at baseline before RPE insertion (T1), directly after RPE insertion (T2), during RPE expansion (T3), during RPE retention (T4), directly after RPE removal but before SABG (T5), and at short-term follow-up after RPE removal and SABG (T6).Ratings for patient and parent questionnaires, first (F1) and second (F2) formants for vowels /a/, /i/, and /u/, and nasalance scores for non-nasal and nasal sentences, were obtained and analyzed using mixed model analyses of variance.Ratings worsened at T2. For the vowel /a/, F1 and F2 were unchanged at T2. For the vowel /i/, F1 increased and F2 decreased at T2. For the vowel /u/, F1 was unchanged and F2 decreased at T2. Nasalance was unchanged at T2. All outcome measures returned to T1 levels by T4.RPE insertion resulted in initial adverse effects on speech perception and production, which decreased to baseline prior to removal. Information regarding transient speech dysfunction and distress may help prepare patients for treatment.

Effects of different calibration schedules on the test-retest differences of nasalance scores obtained with the Nasometer 6450.

Nasometry is used to assess nasality in speech but it is unclear whether overly frequent recalibration of the instrument adds measurement errors. The goal of the present research study was to describe the effect of the Nasometer 6450 calibration on the nasalance scores of repeated recordings. In a first experiment, the Nasometer calibration values stored in the computer's registry were manipulated to investigate the impact on nasalance scores. In the second experiment, a set of pre-recorded speech samples was re-recorded 40 times with a Nasometer 6450 in 4 different calibration regimens: Short-term repeated recordings without (R1) and with recalibration (R2C), and long-term repeated recordings over 10 days without (R3) and with recalibration (R4C). The first experiment showed that, compared to a calibration value of 1.0, a value of 0.9 resulted in nasalance scores that were on average 3 points lower while a calibration value of 1.1 resulted in scores that were 0.5 points higher. The results of the second experiment showed test-retest differences of less than 2 nasalance points for 91% of the data for a non-nasal stimulus. For a nasal stimulus, 91% of data were within 5 points for R3 and R4C. The results suggested that frequent recalibration of the Nasometer may slightly increase test-retest differences of nasalance scores. An alternative procedure for verifying microphone balance without recalibration is suggested.

Covering Nasometer Microphones with Plastic Wrap for Infection Control Increases Retest Variability of Nasalance Scores.

The Nasometer is a popular instrument for the acoustic assessment of nasality. In light of the currently ongoing COVID-19 global pandemic, clinicians may have wondered about the infection control procedures for the Nasometer. The current research investigated whether nasalance scores are affected if the Nasometer 6450 microphone casings are covered with a material such as rolled polyvinyl chloride household wrap. For the experiment, pre-recorded sound files from two speakers were played back through a set of small loudspeakers. Nasalance scores from two baselines and three wrap cover conditions were compared. While there was no statistically significant condition effect in a repeated-measures analysis of variance, the within-condition cumulative differences in nasalance scores were 2 for the initial baseline, 42 for wrap cover 1, 24 for wrap cover 2, 78 for wrap cover 3, and 8 for the final baseline. Mean differences between the wrap cover and the baseline conditions were 8.2 to 15.3 times larger, and cumulative differences were 8.3 to 16.6 times larger than between the two baselines. Based on the higher cumulative and mean differences observed, clinicians should not cover Nasometer microphones with household wrap as this increases variability of nasalance scores. Since there is evidence that the COVID-19 virus can survive for some time on metal surfaces, clinicians should be mindful of the fact that the Nasometer microphone housings can only be cleaned superficially and should be handled with gloves to minimize any possible risk of touch transfer of pathogens to the next speaker or the clinician.

Interlocutor accommodation of gradually altered nasal signal levels in a model speaker.

BACKGROUND: Phonetic accommodation is observed when interacting speakers gradually converge (or diverge) on phonetic features over the course of a conversation. The present experiment investigated whether gradual changes in the nasal signal levels of a pre-recorded model speaker would lead to accommodation in the nasalance scores of the interlocutor in a speech-shadowing experiment. METHODS: Twenty female speakers in two groups repeated sentences after a pre-recorded model speaker whose nasal signal level was gradually increased or decreased over the course of the experiment. Outcome measures were the mean nasalance scores at the initial baseline, maximum nasal signal level, minimum nasal signal level and final baseline conditions. The order of presentation of the maximum and minimum nasal signal levels was varied between the two groups. RESULTS: The results showed a significant effect of condition in F(3) = 2.86, p = 0.045. Both groups of participants demonstrated lower nasalance scores in response to increased nasal signal levels in the model (phonetic divergence). The group that was first presented with the maximum nasal signal levels demonstrated lower nasalance scores for the minimum nasal signal level condition (phonetic convergence). CONCLUSION: Speakers showed a consistent divergent reaction to a more nasal-sounding model speaker, but their response to a less nasal-sounding model may depend on the order of presentation of the manipulations. More research is needed to investigate the effects of increased versus decreased nasality in the speech of an interlocutor.

Effects of Knowledge of Task on Control of Oral-Nasal Balance in Speech.

INTRODUCTION: Previous research has shown that altering the nasal signal level auditory feedback changed the control of oral-nasal balance in normal speakers. The present study investigated whether knowledge of the task and the instruction not to compensate would change the participants' response to the manipulation. METHODS: Twenty participants (10 females) in 2 groups continuously repeated a sentence while their nasal signal level was increased or decreased and fed back to them via headphones, so the speakers heard themselves as more or less nasal, respectively. After the first recording session, participants were debriefed about the true nature of the experiment. They were instructed not to compensate in the second recording session. The outcome measures were the percentage changes of nasalance scores from the first baseline. RESULTS: Statistical analysis using a repeated measures analysis of variance showed an effect of the nasal signal level, F(5,80) = 2.51, p = 0.049, and a nasal signal level by knowledge of task interaction effect, F(5,80) = 3.25, p = 0.019. Post hoc tests showed that the maximum nasal signal level auditory feedback resulted in a significant decrease of nasality from the initial baseline. CONCLUSION: Despite knowledge of the task, speakers were unable to resist compensating. As found in previous research, there was a numerically higher compensation response at the maximum than at the minimum nasal signal level auditory feedback condition.

Immediate effects of voice focus adjustments on hypernasal speakers' nasalance scores.

OBJECTIVES: To explore the immediate effects of voice focus adjustments on the oral-nasal balance of hypernasal speakers, measured with nasalance scores. METHODS: Five hypernasal speakers (2 M, 3 F) aged 5-12 (SD 2.7) learned to speak with extreme forward and backward voice focus. Speakers repeated oral, nasal, and phonetically balanced stimuli. Nasalance scores were collected with the Nasometer 6450. RESULTS: From the average baseline of 34.27% for the oral stimulus, nasalance increased to 46.07% in forward and decreased to 30.2% in backward focus. From the average baseline of 64.53% for the nasal stimulus, nasalance decreased to 64.13% in forward and decreased to 51.73% in backward focus. From the average baseline of 51.33% for the phonetically balanced stimulus, nasalance increased to 58.87% in forward and decreased to 46.2% in backward focus. CONCLUSIONS: Forward voice focus resulted in higher and backward voice focus resulted in lower nasalance scores during speech for a group of hypernasal speakers. However, there was an exception: One male speaker showed decreased nasalance in forward voice focus. Future research should investigate the longer-term effectiveness of the intervention.

Nasalance-Based Preclassification of Oral-Nasal Balance Disorders Results in Higher Agreement of Expert Listeners' Auditory-Perceptual Assessments: Results of a Retrospective Listening Study.

OBJECTIVE: Reliable perceptual and instrumental assessment of oral-nasal balance disorders is a persistent problem in speech-language pathology. The goal of the study was to evaluate whether nasalance-based preclassification of oral-nasal balance disorders improves listener agreement. DESIGN: Retrospective listening study. SETTING: Tertiary university hospital. PARTICIPANTS: Fifty-four randomly selected recordings of patients with repaired unilateral cleft lip and palate (UCLP). Three experienced speech-language pathologists participated as expert listeners. INTERVENTIONS: Two listening experiments were based on nasalance scores and audio recordings of speakers with repaired UCLP. The speakers were preclassified as normal, hypernasal, hyponasal, or mixed based on their nasalance scores. Initially, the listeners determined the diagnostic category of the oral-nasal balance for 62 audio recordings (8 repeats). Six months later, they listened to 38 of the recordings (6 repeats) along with a spreadsheet indicating the nasalance-based categories for the oral-nasal balance. The listeners confirmed, or rejected and corrected, the nasalance-based preclassification. MAIN OUTCOME MEASURES: Intralistener, interlistener agreement, and agreement between listener categories and nasalance-based oral-nasal balance categories. RESULTS: In the first study, the agreement between the listeners' diagnostic category and the nasalance-based category was 45.1% and the interlistener agreement was 36.7%. In the second study, the agreement between the listeners' category and the nasalance-based category was 67.1% (75% agreement for the correct nasalance-based categories and 41.7% for the misclassifications), and the interlistener agreement was 85.4%. CONCLUSIONS: Preclassification of oral-nasal balance disorders based on nasalance scores may help listeners achieve better diagnostic accuracy and higher agreement.

Influence of Voice Focus Adjustments on Oral-Nasal Balance in Speech and Song.

OBJECTIVES: This study investigated the effect of training backward and forward voice focus adjustments on oral-nasal balance in speech and singing in typical speakers. METHODS: Twenty participants (10M/10F) aged 24.25 (SD 3.73) years read phonetically balanced, nasal and oral speech stimuli, and sang a song in both forward and backward voice focus conditions. A Nasometer 6450 was used to obtain nasalance scores in the different conditions. RESULTS: Results indicated that forward voice focus resulted in more nasality (p < 0.01) for the oral stimulus and song. Backward voice focus caused a decrease in nasality (p < 0.01) for the nasal stimulus, the phonetically balanced paragraph, and the song. During production of the song, males were more nasal in the forward voice focus condition than females (p = 0.01). CONCLUSIONS: Voice focus can influence oral-nasal balance in normal speakers. More research is needed to investigate whether voice focus adjustments could be helpful to speakers with oral-nasal balance disorders.

Influence of Altered Auditory Feedback on Oral-Nasal Balance in Song.

OBJECTIVES: This study explored the role of auditory feedback in the regulation of oral-nasal balance in singing in trained singers and non-singers. STUDY DESIGN: Experimental repeated measures study. METHODS: Twenty non-singers (10M/10F) and 10 female professional singers sang a musical stimulus repeatedly while hearing themselves over headphones. Over the course of the experiment, the nasal level signal in the headphones was increased or decreased so that the participants heard themselves as more or less nasal. Nasalance scores in the different phases of the experiment were quantified using a Nasometer 6450. RESULTS: A repeated measures analysis of variance demonstrated a significant main effect for singing condition F(5, 135) = 3.70, P < 0.05, and multiple comparison tests demonstrated that the nasalance scores for final baseline and the maximum and minimum nasal feedback conditions were all significantly lower than the first baseline (all comparisons P < 0.05). CONCLUSION: There were no differences between the singers and non-singers. All participants had lower nasalance scores in response to both increased and decreased nasal signal level feedback.

Speech-language therapy students' auditory-perceptual judgements of simulated concurrent hypernasality and articulation disorders.

Auditory-perceptual judgements are regarded as the standard method for assessing speech disorders. However, the results of auditory-perceptual evaluations and rater reliability can be affected by various factors, such as concurrent problems in multiple speech subsystems. This study investigated the effect of a co-occurring articulation disorder on auditory-perceptual judgements of hypernasality and the effect of co-occurring hypernasality on judgements of an articulation disorder. The speech stimuli were sentences produced by a male speaker who simulated four levels of hypernasality (typical nasality, and mild, moderate, and severe hypernasality) at four levels of disordered articulation (typical articulation, and mild, moderate, and severe articulation disorder). Thirty speech and language therapy students used visual analogue scales to rate the severity of hypernasality and articulation disorder for each speech sample. Results showed that the hypernasality ratings were significantly higher when articulation disorder co-occurred compared to those without. However, there was no significant difference between mild, moderate and severe concurrent articulation disorder on hypernasality ratings. The speech samples with typical articulation and those with severe articulation disorder were rated as more severe in terms of articulation problem when combined with severe hypernasality. However, there was no significant hypernasality effect on articulation ratings for speech with mild or moderate articulation disorder. The present results generally agreed with previous findings regarding the effect of co-occurring speech problems on auditory-perceptual judgements. Clinicians are advised to be cautious of the potential impact. If possible, speech evaluation using instrumental techniques should be used to supplement auditory-perceptual judgements.

Analysis of oral-nasal balance after intensive speech therapy combined with speech bulb in speakers with cleft palate and hypernasality.

OBJECTIVE: To evaluate the efficacy of the combination of a speech bulb with an intensive speech therapy program in hypernasal participants with cleft palate. METHODS: Twenty hypernasal speakers with cleft palate (12 females and 8 males, median age 28.45 years), who were wearing speech bulbs underwent an intensive speech therapy program of 45 sessions over 3 weeks. Three experienced speech-language pathologists rated the participants' speech recordings before and after intensive speech therapy, with and without the speech bulb. Nasometric recordings and long-term averaged spectra were also analyzed using repeated-measures ANOVAs. RESULTS: The ANOVA of the hypernasality ratings showed significant effects of therapy [F (1,19) = 15.97; p < .001], speech bulb [F(1,190 = 28.54, p < .001] and a therapy -speech bulb interaction effect [F(1.19) = 22.30, p < 0.001]. The most favorable listener ratings of hypernasality were obtained post-therapy when participants were wearing their speech bulbs. Without the speech bulb, intensive speech therapy by itself did not result in a significant improvement. With speech bulb, nasalance scores for high [F (1,19) = 14.07, p < .001] and low pressure [F (1,19) = 14.84, p < .001] sentences were significantly lower post-therapy, providing preliminary evidence that an intensive speech therapy program may enhance the effect of a speech bulb. Before and after comparisons of individual nasalance profiles demonstrated variable improvement in 15 participants, no progress in 2 participants and more severe hypernasality after therapy in 3 participants. Long-term averaged spectra corroborated the findings of the perceptual analysis. Based on a frequency bin from 201 to 300 Hz, there was a significant within-subject effect for with and without speech bulb [F(1, 18) = 4.54, p = .047] as well as for before vs. after session [F (1,18) = 7.14, p = .015]. CONCLUSION: The speech bulb in combination with intensive speech therapy resulted in improved oral-nasal balance for the majority of participants. More research is needed to investigate long-term outcomes as well as individual factors contributing to therapy success.

Influence of Altered Auditory Feedback on Oral-Nasal Balance in Speakers of Brazilian Portuguese.

Purpose This study explored the role of auditory feedback in the regulation of oral-nasal balance in speakers of Brazilian Portuguese. Method Twenty typical speakers of Brazilian Portuguese (10 male, 10 female) wore a Nasometer headset and headphones while continuously repeating stimuli with oral and nasal sounds. Oral-nasal balance was quantified with nasalance scores. The signals from 2 additional oral and nasal microphones were played back to the participants through the headphones. The relative loudness of the nasal channel in the mix was gradually changed, so that the speakers heard themselves as more or less nasal. Results A repeated-measures analysis of variance of the mean nasalance scores of the stimuli at baseline, minimum, and maximum nasal feedback conditions demonstrated significant effects of nasal feedback condition (p < .0001) and stimuli (p < .0001). Post hoc analyses demonstrated that the mean nasalance scores were lowest for the maximum nasal feedback condition. The scores of the minimum nasal feedback condition were significantly higher than 2 of 3 baseline feedback conditions. The speaking amplitude of the participants did not change between the nasal feedback conditions. Conclusions Increased nasal signal level feedback led to a compensatory adjustment in the opposite direction, confirming that oral-nasal balance is regulated by auditory feedback. However, reduced nasal signal level feedback resulted in a compensatory response that was lower in magnitude. This suggests that, even in Brazilian Portuguese, a language with phonetic and phonological vowel nasalization, decreased nasality was not perceived as critically as increased nasality by the speakers.

Effect of the Visual Presentation of a Craniofacial Syndrome on Speech Intelligibility in Noise.

OBJECTIVE: Research has argued that a speaker's facial appearance can result in an "intelligibility cost" for the listener. The study investigated whether such an intelligibility cost exists for a visible repaired cleft lip and nasal asymmetry. SETTING: University department. PARTICIPANTS: Eight typical speakers provided speech samples. Twenty-eight naive listeners participated in a speech in noise experiment. INTERVENTIONS: Listeners transcribed sentences in noise that were paired with faces of individuals with repaired cleft lip and nasal asymmetry or typical faces. They also rated speaker intelligibility and answered a questionnaire about their previous knowledge about cleft lip and palate. MAIN OUTCOME MEASURES: Percentage of words transcribed correctly and intelligibility ratings, compared by experimental condition (photo of typical face or face with repaired cleft lip and nasal asymmetry) and speaker gender. RESULTS: There were no statistically significant differences between speech stimuli that were presented with faces with repaired cleft lip and nasal asymmetry or typical faces. The percentage of words transcribed correctly by the listeners was lower for female speakers (F = 12.7, df = 1; P < .01). Speech intelligibility of female speakers was rated more poorly (F = 10.5, df = 1; P < .01). CONCLUSIONS: Presence of a repaired cleft lip and nasal asymmetry did not result in an intelligibility cost for naive listeners. Future research should investigate possible effects of facial motion or previous knowledge.

Clinical Application of a New Approach to Identify Oral-Nasal Balance Disorders Based on Nasalance Scores.

OBJECTIVE: A new approach to classify oral-nasal balance disorders based on instrumental measurements was developed based on linear discriminant analysis (LDA) of nasalance scores of simulated oral-nasal balance disorders by de Boer and Bressmann. The current study aimed to apply the newly developed functions to clinical data to investigate the applicability of this new approach. DESIGN: Retrospective diagnostic accuracy study. SETTING: Tertiary university hospital. PARTICIPANTS: Fifty-five Dutch-speaking Flemish children (age 4-12 years) with normal (n = 20), hypernasal (n = 18), hyponasal (n = 12), or mixed nasality (n = 5). INTERVENTIONS: Nasalance scores of an oral and a nasal text were used to calculate 3 sets of LDA function scores. Predicted classification was consecutively based on the function values of the group centroids originally determined by de Boer and Bressmann and adapted LDA functions and group centroids based on clinical data. MAIN OUTCOME MEASURES: Discriminatory power of the linear discriminant formulas. RESULTS: Based on the original LDA functions, 56% of the speech samples matched the perceptual classification. Applying a correction factor for age and language differences resulted in a 67% correct classification, although 83% of the hyponasal samples were ranked as "normal resonance." Rederivation of the LDA functions based on current clinical data resulted in an 80% correct classification. CONCLUSIONS: The new approach of classifying oral-nasal balance disorders based on a combination of nasalance scores was promising. However, further clinical research is needed to refine the LDA functions and group centroids before clinical application is possible.