Frequency and age effects of secondary health conditions in individuals with spinal cord injury: a scoping review.

STUDY DESIGN: Scoping review. OBJECTIVES: To gain a better understanding of the prevalence, course and association with age of secondary health conditions in individuals with spinal cord injury (SCI). SETTING: Seattle, Washington, USA. METHODS: We performed searches of electronic databases for studies published from 1986-2011 that provided information regarding the prevalence, course or associations with age and duration of secondary health conditions in individuals with SCI. RESULTS: Ninety-two studies were included. The findings indicate that: (1) individuals with SCI experience a number of secondary health conditions, many of which occur at a higher rate in those with SCI than the normative population; (2) the most common conditions or symptoms are pain, bowel and bladder regulation problems, muscle spasms, fatigue, esophageal symptom and osteoporosis; (3) a number of conditions, including cardiovascular disease, diabetes, bone mineral density loss, fatigue and respiratory complications or infections, occur with higher frequency in older individuals or those with longer SCI duration, relative to younger individuals or those with shorter SCI duration; and (4) there is a marked lack of longitudinal research examining the natural course of health conditions in individuals aging with SCI. CONCLUSIONS: The findings support the conclusion that individuals with SCI show signs of 'premature aging' in different organ systems. Longitudinal research is needed to understand when problems are most likely to emerge, and to develop and test the efficacy of interventions to prevent these health conditions and their negative impact.

Setting the agenda for multiple sclerosis rehabilitation research.

BACKGROUND: Recognizing the need for more evidence-based multiple sclerosis (MS) rehabilitation, in the mid-2000s several initiatives were undertaken to explore why there had been a paucity of such research and to determine strategies to reverse this pattern. EXPERT-OPINION-PAPER: In 2004 the National Multiple Sclerosis Society (NMSS) convened an expert opinion panel, reviewed evidence-based MS rehabilitation research, and published the paper on the web. It was concluded that much of the MS rehabilitation carried out was based on experience, with little research backing it up. INCREASING THE QUALITY AND QUANTITY OF MS REHABILITATION RESEARCH: Largely as a result of the conclusions of the Expert-Opinion-Paper, the NMSS convened a conference of a large number of MS and rehabilitation experts in New York in May, 2005. This conference made many recommendations of ways to increase the quantity and quality of MS research. STATE OF THE SCIENCE CONFERENCE: In September, 2006, a follow-up conference was held in Washington, D.C... This conference, primarily sponsored by the University of Washington Multiple Sclerosis Rehabilitation Research and Training Center (MS RRTC), focused on some of the under-studied "hidden" disabilities present in persons with MS. This paper discusses the details and recommendations of these latter two conferences.

Accuracy of metamemory after traumatic brain injury: predictions during verbal learning.

The primary intent of this study was to investigate the metamemory monitoring abilities of adult survivors of at least moderate traumatic brain injury (TBI) during a verbal-learning activity. Eighteen survivors and 18 non-injured control participants made judgment-of-learning (JOL) predictions of their recall ability immediately after studying 3 lists of noun-pairs or after a slight delay. A secondary intent of this study was to determine if verbal retrieval attempts would enhance predictive accuracy. One half of participants made retrieval attempts during the second and third list-learning task, and the other half made retrieval attempts during the third list-learning task only. Measures of the correlation between JOL predictions and recall accuracy revealed that survivors were as accurate as controls when making delayed predictions and were less accurate when making immediate predictions. This occurred regardless of retrieval attempts. Absolute measures that compared mean JOL ratings to overall recall revealed that the survivor group was well-calibrated when making delayed JOL predictions but overestimated when making immediate JOL predictions. The non-injured control group underestimated when making both types of predictions. However, within-group variability was high. These findings are compared to those from studies that investigated metamemory beliefs in which survivors' ratings were compared to family-member ratings. Clinical implications for basing executive decisions about compensatory strategies on delayed and immediate predictions of future recall are discussed. Additionally, a rationale is provided for the use of both relative and absolute measures of predictive accuracy in metamemory studies involving neurological clinical populations.

Presentation of ALS to the otolaryngologist/head and neck surgeon: getting to the neurologist.

Patients with early symptoms of bulbar amyotrophic lateral sclerosis (ALS) are usually referred to the otolaryngologist without a diagnosis. Careful examination of the speech quality and a physical exam, including the vocal cords, should be undertaken. The emotional state of the patient should be considered, and a diagnosis should not be offered before a neurologic consultation has been obtained. Patients with late symptoms of bulbar ALS almost always present with both significant speech and swallowing abnormalities. Evaluation can be difficult because many abnormalities are found on examination. Advanced progression of symptoms is a clear indication for rapid referral to a neurologist if a diagnosis has not already been made. Supportive and symptomatic care should be offered to the patient immediately. The University of Washington Neuromuscular Clinic for Speech and Swallowing Disorders has seen 600 new neurologic patients since 1986, 211 of whom were ALS patients. The introduction of percutaneous gastrostomy has greatly changed the management of ALS patients, and 75 patients have undergone this procedure (32% because of inadequate swallowing, 68% for declining vital capacity). Medical management to improve symptoms may be indicated before surgery. Surgical options for patients with late salivary presentation are uncommon and include removal of the submaxillary glands, tracheostomy, and laryngeal or salivary diversion procedures. Laryngectomy or laryngeal diversion procedures are only very rarely indicated. Although tracheostomy usually interferes with swallowing and worsens aspiration, it may rarely be indicated in patients with late airway presentation for glottic narrowing or artificial respiratory support. Symptomatic management of patients with bulbar ALS is usually best undertaken by a multidisciplinary clinic that can provide a physically and psychologically supportive environment.

Functional outcome assessment in dysarthria.

Strategies for the functional assessment of communication disorders experienced by persons with dysarthria can be based on the Chronic Disabilities Model described by Nagi (1991), which considers a disorders at five different levels, ranging from pathophysiology at the level of the tissue to the societal levels of dysfunction. Outcomes can be measured at all levels of the model. For example, at the pathophysiologic level, outcomes may indicate events at the tissue level during the course of the disease, whereas, at the level of the disability, outcomes reveal the adequacy of speech production using compensatory strategies in communicative contexts, and at the societal level, they may indicate the overall degree of success a speaker has in specific real-world speaking situations. This article focuses on "functional" assessment of persons with dysarthria. Thus, assessment is viewed from the perspective of how speech and the use of speech can be measured in functional situations over time or as a result of treatment.

Written language production and neuropsychological function in children with traumatic brain injury.

OBJECTIVE: To establish the early consequences of traumatic brain injury (TBI) on spontaneous written language production in children by examining writing deficits as a function of injury severity and correlating written performance with neuropsychological data. DESIGN: Case-control cohort study. SETTING: Two regional medical centers. PATIENTS: Seventy-six children, aged 8 to 15 years, with mild, moderate, or severe closed head injury were compared with controls who were individually matched on the premorbid characteristics of age, gender, school grade, behavior, and academic performance. MAIN OUTCOME MEASURES: Assessment of written language production and neuropsychological function was undertaken approximately 1 month following resolution of posttraumatic amnesia. Case-control differences on 16 measures of spontaneous written narratives were computed. RESULTS: Factor analysis and conceptual similarities suggested that the measures of written language fell into five domains: Efficiency, Completeness, General Readability, Error, and Vocabulary. A highly significant, moderate correlation between these measures and severity of injury was found. The highest correlations were found for the written language domains of Efficiency and Completeness and the lowest for the Vocabulary domain. Moderate correlations were also found between measures of written language and neuropsychological function. CONCLUSIONS: At 1 month after resolution of posttraumatic amnesia, written language production in children with TBI is negatively correlated with severity of injury. Some aspects of written language production are affected to a greater extent than others. Considerable common ground was found between written language production and neuropsychological function.

Speech and pause characteristics following speech rate reduction in hypokinetic dysarthria.

The effect of speech rate reduction on speech and pause characteristics during a reading task was examined for speakers with Parkinson's disease (PD) and a group of control speakers. Duration of utterances and characteristics of pausing (duration, interpause phrase length, and location) were determined. At habitual reading rate, subjects with PD had shorter speech duration and greater time per pause than control subjects. At reduced reading rates, subjects with PD increased speech duration so that it was equivalent to the control speakers at habitual rate. Both groups had the majority of their pause occurring at appropriate syntactic boundaries. Subjects with PD had a greater proportion of pauses occurring at syntactically inappropriate locations than did the controls. When speech rates were reduced, both groups showed a decrease in pauses located at appropriate syntactic boundaries. The implication of these findings on speech intelligibility is discussed.

Treatment efficacy: dysarthria.

The dysarthrias form a group of diverse, chronic motor speech disorders. The disorders of Parkinson's disease, stroke, traumatic brain injury, amyotrophic lateral sclerosis, and cerebral palsy are reviewed because they represent important clinical diagnoses in which dysarthria is a frequent and debilitating symptom. The roles played by speech-language pathologists include participation in differential diagnosis, provision of speech treatment, staging of treatment, and timely education so that clients and families can make informed decisions about communication alternatives. Both scientific and clinical evidence is presented that suggests that individuals with dysarthria benefit from the services of speech-language pathologists. Group-treatment studies, single-subject studies, and case reports illustrate the effectiveness of various types of speech treatment. Research into the effectiveness of augmentative and alternative communication systems for individuals with cerebral palsy is also presented.

Management of oral-pharyngeal dysphagia symptoms in amyotrophic lateral sclerosis.

Oral and pharyngeal dysphagia is a common symptom in patients with amyotrophic lateral sclerosis (ALS) and is the result of a progressive loss of function in bulbar and respiratory muscles. Clinicians involved in the management of ALS patients should be familiar with the common clinical findings and the usual patterns of temporal progression. The prevention of secondary complications, such as nutritional deficiency and dehydration that compound the deteriorating effects of the disease, requires careful monitoring of each patient's functional status and timely intervention with appropriate management techniques.

Differential phonatory characteristics of four women with amyotrophic lateral sclerosis.

Patients with specific neural subsystem involvement are often reported to present with particular perceptual characteristics of voice. This has been true for diseases such as amyotrophic lateral sclerosis (ALS), a progressive disease in which mixed neurologic signs are present. This article reports acoustic data on the phonatory performance of four women diagnosed with ALS who had initial bulbar signs and progressive phonatory deterioration. The data presented here demonstrate that the phonatory characteristics of women with ALS are not uniform, but in fact may vary greatly from patient to patient.

Effects of temporal alterations on speech intelligibility in parkinsonian dysarthria.

The effect of two types of temporal alterations, paced and synthetic, on the intelligibility of parkinsonian dysarthric speech was investigated. Six speakers with idiopathic Parkinson's disease served as subjects. Paced temporal alterations were created by slowing each speaker to 60% of his/her habitual speaking rate. The synthetic alterations were created by modifying the habitual rate speech samples using digital signal processing. Three types of synthetic alterations were examined: Pause Altered, Speech Duration Altered, and Pause and Speech Duration Altered. The 60% of habitual speaking rate condition was more intelligible than the synthetic conditions. In addition, none of the synthetic alterations were found to be more intelligible than samples produced at habitual speaking rates. The results suggest that simple alterations of speech signals do not explain the differences in intelligibility that have been observed when parkinsonian dysarthric speakers reduce speaking rates. Reasons for the failure of synthetic alterations to increase speech intelligibility scores are discussed.

The effect of rate control on the intelligibility and naturalness of dysarthric speech.

Speaking rates of individuals with severe ataxic dysarthria (n = 4) and severe hypokinetic dysarthria (n = 4) were reduced to 60% and 80% of habitual rates using four different pacing strategies (Additive Metered, Additive Rhythmic, Cued Metered, and Cued Rhythmic). Effects of rate control on sentence and phoneme intelligibility and speech naturalness were examined. Sentence intelligibility improved for both groups, with metered pacing conditions associated with the largest improvement in scores. Similar improvements as speaking rates were reduced were not seen for the phoneme intelligibility task; however, one must recognize that sentence and phoneme intelligibility tasks are different. Slowing the rate of dysarthric speakers did not have as marked an impact on speech naturalness as it did for normal speakers whose naturalness decreased at slowed rates. Metered rate control strategies were associated with the lowest ratings of naturalness for all subject groups. A potential explanation for the discrepancies between the findings for sentence and phoneme intelligibility is offered.

Extended communication samples of augmented communicators. I: A comparison of individualized versus standard single-word vocabularies.

Vocabulary selection for linguistically intact augmented communicators is a growing clinical concern. The purpose of this study was to compare and contrast the relative benefits of word lists that were individualized for these augmented subjects to word lists selected from standard vocabulary sources. Communication samples were collected for 14 consecutive days from 10 subjects who used augmentative and alternative communication (AAC) devices. These samples were analyzed to determine the frequency of single word occurrence, and the results were compared with those obtained from analysis of standard vocabulary lists. The conclusions of the study were (a) that when vocabulary lists are individually created, based on the frequency of word occurrence in natural communication samples, relatively short lists can represent a large proportion of the total communication sample; (b) that individualized word lists are more efficient than standard vocabulary lists, if efficiency is defined as a large proportion of the total sample represented by a small list; and (c) that if used in their entirety, standard lists are not efficient because they contain a large number of words that are rarely used.

Extended communication samples of augmented communicators. II: Analysis of multiword sequences.

The three primary purposes of this project are (a) to identify those word sequences that occur frequently across a group of 10 linguistically intact augmented communicators, (b) to determine the communality with which the various augmented communicators use specific word sequences, and (c) to evaluate the usefulness of word sequences in providing keystroke savings for users of augmentative and alternative communication (AAC) devices as compared to letter-by-letter spelling or single-word retrieval. Communication samples were collected for 14 consecutive days from 10 subjects who used AAC devices. These samples were analyzed with custom software to determine the frequency of occurrence of one-, two-, three-, four-, and five-word sequences. The results revealed that three-, four-, and five-word sequences occurred very infrequently within and across communication samples. Two-word sequences occurred much more frequently than the longer sequences. The authors concluded that clinicians should continue to encourage linguistically intact clients to select long messages (three words or more) for their AAC devices based on message content and the urgency with which messages need to be delivered rather than relying exclusively on statistical analysis. However, statistically based multiword analysis should not be abandoned. Frequently occurring one- and two-word sequences may be an important source of messages that will increase communication efficiency when stored and retrieved in an AAC device.

Using phonation time to estimate vital capacity in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a neuromuscular disease in which progressive respiratory weakness is usually the proximate cause of death. Since continued assessment of respiratory function is important in predicting progression, phonation time was measured in a group of 41 ALS patients and correlated with measured vital capacity. The findings show that the variance in phonation time accounts for nearly 50% of the variability of vital capacity, and therefore, successive measurements of phonation time are a useful means of estimating the loss of vital capacity.

Perceived articulatory adequacy and velopharyngeal function in dysarthric speakers.

Twenty-four dysarthric speakers with etiologies of brain injury or stroke were placed into one of two groups based on aerodynamic measures of velopharyngeal status. Group I contained 13 individuals who were velopharyngeally incompetent in that nasal air flow was always noted during the stop phase of voiceless plosive sounds. Group II contained 11 individuals who at times achieved complete velopharyngeal closure. Certain measures of perceived articulatory adequacy were found to distinguish between the two groups. Specifically, speakers who were velopharyngeally incompetent produced an articulatory error pattern characterized by better performance for the consonant subcategory nasals-glides than for pressure consonants. Speakers who at times were achieving velopharyngeal closure did not exhibit a marked difference between these two consonant subcategories. Clinical use of measurement of articulatory adequacy as a gross indicator of velopharyngeal competence is suggested and limitations are discussed.

Amyotrophic lateral sclerosis severity scale.

The amyotrophic lateral sclerosis (ALS) severity scale has been developed to provide an ordinal staging system and a means of rapid functional assessment for patients with ALS. The scale allows an examiner to evaluate the symptoms of ALS numerically in four categories that describe speech, swallowing, lower extremity, and upper extremity abilities. These scores, combined with a vital capacity measured on a hand-held respirometer, provide a rapid, accurate assessment of a patient's disease status and can be used for treatment planning. The ALS severity scale has been shown to have an average estimated reliability coefficient of 0.95 between examiners. Speech ratings were correlated greater than 0.80 for objective speech measures. Rates of progression of the total score in a small group of patients ranged from -3.4 to -24.0 points/year with a mean of -11.3 points/year.

Articulatory adequacy in dysarthric speakers: a comparison of judging formats.

An articulatory inventory was administered to 19 dysarthric adults and scored using two judging formats--phoneme identification and traditional testing. Results indicated that samples judged using the traditional testing format, in which the judge knew the target phoneme, were consistently scored more accurately than those that had been judged using a phoneme identification format, in which the target was not known. Although overall both judging formats were characterized by high inter-rater reliability, the traditional testing format was less reliable than phoneme identification with samples obtained from severely involved speakers. Potential uses of articulatory inventories for dysarthric adults are described.

Speech-muscle visuomotor tracking in dysarthric and nonimpaired speakers.

Assessment of speech-muscle function during nonspeech tasks may provide an important component in the clinical evaluation of speech-motor disorders. Various methodological problems have limited the value of such data in the past. The goal of the present study was to evaluate a set of instrumental, objective procedures for assessment of the nonspeech performance capabilities of different speech-muscle systems. Subjects included 10 nonimpaired adults and a diverse group of 6 adult dysarthric individuals. Each subject performed visuomotor tracking of a 0.6-Hz sinusoidal target with the lower lip, jaw, larynx, and respiratory systems. Cross correlation and phase data were used to describe tracking performance. The nonimpaired subjects showed consistently high cross correlations with little phase shift. The dysarthric subjects showed a wide range of tracking performance which was generally consistent with their overall levels of speech performance and levels of neurological impairment. Differential levels of performance were noted across speech subsystems in some dysarthric subjects. In general, the results suggest that visuomotor-tracking paradigms provide a viable approach to clinical evaluation of speech-muscle function in nonspeech tasks.

Communication options for intubated patients.

The number of communication options available to intubated patients is rapidly increasing. Selection of an appropriate augmentative communication approach depends on the decision-making practices of a team of experts. A series of oral and nonoral augmentative communication options is reviewed here, with particular emphasis on patients who are candidates for each approach.