On this episode of the Swallia pride podcast,
we have an awesome research team, which I
am so, so happy to have them on.
We have Connor Daughtridge. She's the one that
wrote in to be on the podcast, and
I had the fortunate opportunity to meet Connor
at ASHA, and I and I really, really
enjoyed talking with her.
She is a research SLP employed by Atrium
Health in Charlotte, North Carolina,
partnering with the CARD Lab at UNC Chapel
Hill working on the speech profiles and cue
responsiveness after left hemisphere stroke study.
She holds a master's degree in speech pathology
from UNC at Chapel Hill. Her primary clinical
and research interests are aphasia and apraxia of
speech. Previously, she worked at inpatient rehab at
Novant Health New Hanover Regional Medical Center in
inpatient rehab and acute care.
And she is joined by doctor Katerina Haley.
Katerina is a professor in the division of
speech and hearing sciences. She specializes in the
in the assessment and treatment of adults with
left hemisphere brain injury.
Her greatest areas of interest include the perceptual,
motor, and language mechanisms that influence speech production
in aphasia and apraxia of speech, the development
of quantitative speech assessment procedures for clinical applications,
and the development of procedures and materials to
support self determination in people with aphasia.
She received her training in speech language pathology
at the Karolinska
Institute in Stockholm and her graduate training at
Vanderbilt University. She teaches courses in aphasia, neurologic
communication disorders, and research design.
And we are also joined by doctor Adam
Jacks. Adam is an associate professor in the
division of speech and hearing sciences.
He teaches courses in speech science and neuromotor
speech disorders.
His research focuses on understanding the link between
neuropathology
and behavioral manifestations of neurological speech disorders,
investigating novel interventions for people with aphasia,
and identifying factors associated with improved quality of
life with aphasia.
After receiving his master's and PhD degrees in
communication sciences and disorders at the University of
Texas at Austin, he completed a postdoctoral fellowship
in behavioral neuroimaging
at the Research Imaging Institute at the University
of Texas Health Sciences Center at San Antonio.
Hope and I hope you all love this
episode. I just really enjoyed talking to this
team. They're doing really, really, really cool work,
and I super appreciate them wanting to come
on the podcast.
Welcome to the Swall Your Pride podcast. I'm
your host, Teresa Richard. Richard. I'm a board
certified specialist in swallowing and swallowing disorders, a
mobile thieves business owner, and founder of the
MedSLP Collective.
This podcast is all about delivering the latest
evidence based practice to medical SLPs everywhere.
Whether you're a new clinician seeking tangible tools
for treatment or a seasoned vet stuck in
a rut, my goal is to help ditch
the old school ways of the past that
no longer serve you or your patients, to
reinvigorate your passion for our field, to broaden
your knowledge about our scope of practice, and
to inspire you to practice at the top
of your license.
So if you're listening, I encourage you to
swallow your pride, be open and willing to
learn because let's face it, your patients deserve
that kind of care. With that, let's dive
right in.
Just a quick disclaimer that all statements and
opinions expressed in this episode do not reflect
on the organizations associated with the speakers and
are their own opinions solely. Thank you all
for joining me. We've got a packed house
today, which is exciting. I I love episodes
where we've got lots of voices coming together
to to chime in on a topic. So,
welcome, welcome. Thank you all for joining me.
I'd love for each of you to tell
the people a little bit about yourself. So,
Connor, we'll start with you.
Perfect. I can get started.
And I'll start by introducing myself and the
Grander team a little bit.
So all three of us on today are
part of the research team working on the
study speech profiles and cue responsiveness
after left hemisphere stroke,
which is an NIH funded study that has
several aims. But
simply put, we are working to better define
and differentially diagnose between dysarthria,
apraxia, and aphasia with phonemic paraphasia.
And doctor Haley will get into the details
on that a little bit more in a
few minutes.
The study does have two main sites, UNC
hospitals in the Chapel Hill area
and then Atrium Health in the Charlotte area,
both in North Carolina.
And I am one of the research speech
therapists at Atrium Health, and my main role
is to screen, contact, consent, and then test
the eligible,
stroke participants.
And we'll get more into what testing looks
like shortly as well.
Connor, is your only role research Research SLP,
or do you do you treat as well?
You just do research? Only research right now.
Yep.
I've I've heard of a few more, you
know, like, a few more roles that are
popping up like that. I'm like, you literally
just do research. That's so cool. So that's
awesome. Thank you for sharing that with us.
My name is Adam Jacks, and I'm co
investigator
on this project.
And and my role on this project
focuses primarily on, test
stimulus development
and acoustic analysis,
procedure development, and generally supporting the team.
Katarina is the principal investigator, but we we
work very closely together on developing analyses, working
with the team, getting the rest of the
team coordinated, and,
also in disseminating what we've learned.
Outside of this project,
I also teach
graduate and undergraduate
students at UNC Chapel Hill. So I teach
the undergrad
speech science course since I'm really interested in
speech acoustics.
And then I also teach the graduate motor
speech disorders class.
I'm Katarina
Haley.
Theresa, I really appreciated
how you said about, like, it's so cool
that you can work on research.
We we have a team here that is
very,
it's very mixed. So they're clinical researchers, and
I'm one of those Adam is another one
of those. And then we have several practitioners
that are
clinicians,
and we really value that because we're working
together to solve some problems.
And I think that's really one of the
strengths of our pro of our project. So
even though Connor is doing research, it's it's,
like, very applied research. It's research with, you
know, real patients that have had real strokes
and,
and all of that stuff. So yeah, so
I'm the principal investigator
on this project. And that means that it's
my job to take care of the team
to make sure we're all working together and
that we're achieving the goals that we
have.
And because we're at the same time trying
to improve practice for speech language pathologists,
and also advance,
our understanding
of how the brain works, how the left
hemisphere works,
and how it reacts to stroke, we,
we have to work together. And it's really,
really essential that we're addressing both practical questions
and also at the same time innovation
and discovery,
and,
to have an openness that there may be
different conclusions from what we had, like, anticipated
at first. And so that's that's my role.
I
besides supporting the team
and making sure everybody feels comfortable.
I
help with various types of analysis,
administrative work and interpretation.
And then, of course, writing articles and doing
conference presentations
and
writing grants and things like that.
And also sharing the resources that we're developing,
which we'll touch on a little bit later.
Awesome. Awesome. Well, welcome all of you. So
nice to meet all of you. Thank you
for being here. Alright. So so let's dive
in. Where where should we start? Connor, do
you wanna give us a an overview?
Yeah. I can get us started.
So I'll just kinda begin with why we
wanted to come on the podcast in general.
As we said, a large part of the
study is to better define apraxia of speech
and to create some more objective measures that
clinicians can use to take the guesswork
out of diagnosing AOS.
And we've been updating the speech therapists at
our sites that we recruit from, but we
just thought why not reach more SLPs through
this platform.
So that's kind of why we're here.
And how we have it set up a
little bit is we'll move through the continuum
of care as a stroke survivor would and
kind of explain the challenges throughout, and then
we'll get more into the details on the
study and the definitions and wrap up with
the acoustic and perceptual analysis that we're using
and, have developed so far, and then kind
of the future direction for upcoming research ideas
and and resources that we are aiming to
share with the SLP community.
Beautiful.
And I just wanted to just chime in
here and say that one of the things
that we decided early on was that we
were going to do this,
project,
about this dilemma of how do you diagnose
apraxia of speech, which is, like, a long,
recognized,
dilemma. Like, it's not easy.
But we decided early on that we were
going to focus
our study on the first few months after
stroke,
because this is when speech language pathologists are
seeing,
these patients, evaluating,
diagnosing, and treating.
And,
we wanted our participants to be representative
of actual patients that speech pathologists
seen see. And this is this is different
from most other treatment or, most other assessment
studies rather on apraxia of speech in that
they typically
look at people who are at least six
months post onset,
and we're looking
at zero months to six months post onset.
So we'll begin with acute care.
There is when a patient comes into the
hospital with a stroke, there's kind of just
a flurry of
evaluations and a revolving door of medical professionals
trying to see them. And any speech therapist
who has worked in acute care knows that
dysphagia is the primary concern at that time.
Everyone wants to know, can they eat? Can
they drink? Can they take their medications?
So there's a lot of extraneous factors that
really influence and play a role in what
you're able to do.
And the patients have just gone through a
traumatic and life altering medical event, so they're
emotional, fatigued, and they might have limited endurance.
So you really have a limited amount of
time with them overall where you're trying to
gather as much information as possible.
And not to mention, they're also in pain
and on many medications at that time too,
which can impact alertness and attention.
So it is kind of messy when they
first come in. But the goal at this
stage is to set a positive tone for
speech therapy from the get go
and help the patient communicate with their families
and care team
and really start instilling confidence in the communication
modalities that they do have.
And so even though we're not suggesting a
formal diagnosis at this time for someone with
apraxia of speech,
we do wanna talk a little bit about
what informal assessment might look like.
So every speech therapist knows who works in
acute care. You're gonna start with that chart
review, reviewing their,
medical history that is pertinent and then reviewing
those scans, so the MRI or CT scans.
And that's really gonna help you predict what
their deficits may be and kind of tailor
your assessment a little bit based off of
that. Yeah. And I'll say a little bit
more here too. At this point, we don't
necessarily think that, okay, if we look at
the brain scan, the MRI, or the CT,
that we're gonna be able to know exactly
what a person is going to be able
to do.
But we think it's important that SLPs
feel confident that they can take some clues
and say and start to make some
maybe some predictions about, well, what do I
think I might see in in
do I hear what I expect that I'm
going to hear when I look at the
the scans?
And we look we're talking only about the
left hemisphere in this study, and so it's
you know, we we expect generally that a
lot of people are gonna have aphasia.
They may have some difficulty
with,
formulating what they wanna say, coming up with,
with words, word finding.
But, yeah, we have some ideas. Okay. If
it's a frontal lesion, then maybe we're going
to expect to experience
apraxia of speech or maybe a nonfluent ephasia.
If there's something
that is more posterior, we might expect something
that's a little bit more fluent. But, really,
everybody's a little bit different, and they they
give us different profiles. And
when I,
you know, I draw the the side of
the brain for my students. I'm I'm doing
it in the air here. I know we're
on audio here. But there's there's this big
section in the middle,
where
middle cerebral artery strokes are what we see
most of the time, and they overlap in
all these different areas. And so,
you know, we might expect some motor planning
difficulties. We might expect some neuromuscular weakness, maybe
some dysarthria, and we might also expect aphasia.
And ever since Katerina and I have been
working together, we we were just sort of,
like, looking at,
like, what's being done in the field, and
a lot of the field was trying to
pick a pow pick apart
mild isolated disorders, and we were really interested
in, like, well, what do people look like,
reality and in in recognizing the messy reality
that we have a lot of overlap in,
in conditions, different
multiple things are going to exist in the
same person. So,
anyway, I just wanted to talk a little
bit about that and things that we we
we can start to see, like, well, what
do we
if
if we think that we're going to,
see small if we see small vessel disease,
a lot of tiny little strokes, we might
start to wonder, hey. Should we be looking
at cognition a little bit more?
But that happens alongside with dysarthria and apraxia
and aphasia.
Thank you for saying that, Adam. I I
struggled a bit in acute care, you know,
with with reading these MRIs and reading where
the stroke happened in the brain. And I'm
like, shouldn't this be more clear cut? You
know? Shouldn't if x happens, then they present
with y. You know? And and anybody that
that works clinically knows that is not the
way. But I do feel like there could
be more
guidelines or guardrails. You know? So so thank
you for saying that because I think those
of us that have worked clinically
feel like there should be some some better
guardrails. So thank you for doing this work.
I think that this is something that is
happening now. Like, it's not just our team.
There are other teams as well that are
looking at it. And the thing that has
been missing in the past is that there
haven't been any large studies,
you know, because when you're looking for patterns
like that, you wanna, like, have probabilities of
what causes what. And, like, in general,
you need large sample sizes.
Well, how many I might be skipping ahead
here, but how many patients are you guys
hoping to include in the study?
Several 100. So far, we have four about
four hundred and fifty people, who are stroke
survivors.
Yeah. Well, thank you for adding that.
And I do agree from the clinical perspective,
it is very needed.
And like you said, Theresa, the guardrails would
be very nice to have a little bit
more guidance on.
But yeah. So as you are gathering that
information, you do kind of start to gather
a hypothesis on what what I might be
looking for walking into the patient's room. And
so as soon as you meet them, you
know, you start observing their informal conversation.
Are they responding to me? Are they trying
to greet me when I walk in the
room?
Even if they can't verbalize, are they trying
to gesture and point to communicate with me?
If they are verbalizing,
do they have effortful speech? Is it labored
breath, imprecise articulation?
How intelligible are they? Are there any motor
issues? Any hemiparesis? These questions are just kind
of going in the back of your mind
as you're talking with the patient and working
with them because you're trying to gather information
as or you're trying to gather as much
information as you can on their language and
motor speech function,
in an informal way in case you don't
have time to do it more formally in
that setting, and likely you won't.
And that's you know, you're just kind of
assessing informally for aphasia, dysarthria, voice, and apraxia
of speech as you go.
And,
I'll jump in here too to say a
little bit. When we were first conceptualizing
this study, this kinda goes to what I
was saying about the we expect to see,
overlapping
difficulties
in language and speech programming and speech execution.
So we we try to be really intentional
about
what are the things that we're asking people
to do so that we can
really identify
those distinct
problems in in the same people.
Because it's a research study, we're doing a
lot more in an early stage than most
people would do. So typically, one of our
evaluations
might last a couple of hours,
all in.
But we're not saying that that's what should
typically happen in the in the acute stage.
But but we are trying to figure out,
okay, like, from this larger sample,
what are
procedures that we think will be more useful
to clinicians when they only have a few
minutes,
you know, to check-in in
every day?
And so we yeah. We're looking to make
sure that we sample from
language, speech motor planning, execution.
And we tend to find we've been curious
and suspicious for a long time that we're
really we are really interested in apraxia of
speech, but we start to listen to people
when we say, do I have a little
bit of dysarthria there?
Am I am I hearing some some differences
in the voice? Am I hearing some differences
in resonance?
And so we've we've made sure that we've
included some,
tasks and some analysis procedures where we can
figure that out. And, of course, also the
same thing. We're we're sampling language as well.
And then kind of last thing on
on the evaluation portion in acute care, you
just wanna make sure that you're doing that
oral MEC exam, and that is typically included
in the clinical swallow assessment, which you have
to do absolutely,
for patients who have come in with a
stroke. But it can also provide a lot
of insight on, you know, if the patient
has dysarthria
or dysphagia.
Because, again, from our point of view, when
diagnosing
apraxia of speech, we really aren't interested in
or we don't think it's very practical always
in the acute setting because
the patient is just changing so rapidly,
and your time is so precious with the
patient at that time. And as the SLP,
you wanna provide counseling and communication access, and
then that formal diagnosis is better to come,
later on down the road once they've been
given some time to adjust and,
have become a little bit more stable.
Connor, I want to just add to that
the how precious the time is because I
think that
that's an area where a lot of times
we can do better work,
in that,
you know, we may feel like our job
is to evaluate and try to figure what's
going on and how it's changing rapidly during
the first few days post stroke.
But that's also a time where,
patients are in extreme need of reassurance,
and communication access and just information for for
family for them to,
just get in a space where they're ready
to move forward in their rehabilitation.
And this is one of the things we
hear later on that people feel like they
didn't get the right counseling.
They didn't they didn't get reassured. They were
really worried. They had, like, misconceptions
about what was gonna happen later on. So,
it's really, really, really important that speech pathologists
focus on the person,
in the acute care and the family and
provide them with,
with communication access and information
at that point.
So
when it comes to diagnosing speech specifically,
sometimes we can do it just by intuition.
Like, an experienced clinician that has seen hundreds
and thousands
of cases, they we have
a picture of, like, what the whole profile
looks like, and we can identify this just
so I can hear that this is a
praxiom speech,
or it's a praxiom speech with coexisting dysarthria,
for example.
But the truth of it, and this is
something that's new in this in our research
is that sometimes it's not clear.
Sometimes it's not clear what it is, and
it's not a textbook case.
And it can also change,
as Connor mentioned, like, rapidly.
But in those cases, what we are,
wanting to say is that
this is normal
and it's okay to not have a confirmed
diagnosis.
And it's okay for that picture to become
clearer and clearer
certainly in acute care. But also after that,
like, it's it's okay for it to kind
of evolve. So,
we'll get into that more. But once you
get into later stages of recovery, then you
can become,
more analytical if it isn't, you know, yet
clear and, like,
just really look at the features
and see how the features features come together
and then use reasoning
to, to arrive at a diagnosis. But that's
not what you would do in an acute
care setting. It would be more intuition and
just information gathering and okay. Just say,
yep. We suspect this, but we don't know.
So, Katerina, you mentioned that timing was is
very crucial for this study.
Are you willing to share when did you
evaluate these patients? How soon
post stroke and were there multiple points of
measurement or just
yeah.
Yeah. So we we this is a study
that's just done in at one point in
time. So we're asking people for two hours
of their time.
And,
it's a lot.
So
we are we're open to,
to see them anywhere,
typically within the first six months. We've extended
it so we do see some people who
are more chronic as well. But the vast
majority of them are seen before the six
month mark.
Some are
seen day two after stroke,
and then some are seen,
you know, six months after.
We make contact with them early on while
they're in the hospital.
We we talk to them and establish,
you know, a relationship.
And then it's up to them when they
feel comfortable to be assessed.
Are are you noticing any big difference between
maybe two days post stroke verse
six months post stroke as far as the
data that you're collecting? Yep. Yeah. We
well, so there's the,
there's the variable of of,
severity. Like, so what we don't have the
answers to this yet, and this is something
we want to pursue in further research
is the the trajectories,
because you're gonna see different trajectories.
Right? So there's some people who end up
with, let's say, chronic apraxia of speech
for the rest of their lives. Often they're
very
severe, after the stroke,
and,
they typically don't want to be tested. They're
sometimes they're not even testable,
because they have
their they have very little output.
And they're
then we try to scale schedule them later
on,
when they have recovered a bit.
And then there's some people who have some
milder speech issues that they may not even
recognize,
you know, as such, because there's so many
other things happening and they might get discharged,
quickly
and then maybe like lost
to to follow-up. And so we're interested in
both of those, and I I don't know
if I'm answering your questions here, but for
sure people are evolving.
And in this study, we're not able to
track that Yeah. Because we're letting them choose
when we see them, and we're looking at
just the whole picture of different profiles.
Yep.
Makes sense.
We do have a little bit of
we we can look at their medical
chart to see, you know, what the speech
therapist was saying initially and then when at
the time of testing, if they've improved a
lot. So we look at that I mean,
it's not a main focus of the study,
I would say, but we you can look
at it a little bit.
Yeah.
Alright. Well, I will just kinda jump back
in with where we left off if that's
okay. Yep. So after the patient moves on
from acute care and they
begin to get more medically stable, they're gonna
leave the hospital and either go home and
maybe receive home help or outpatient,
or if they have more physical needs, they
will go to inpatient rehab.
And in this setting, we do think it's
a bit easier and more necessary to provide
that more formal diagnosis,
because overall, they are improving, and that's when
the therapy really
starts,
going. So their medications are being sorted out
and better refined.
The people are they're getting dressed at that
time, and that really improves identity and motivation
and positivity.
Their schedule is a little bit more regular,
and so their endurance is improving and fatigue
is less of a factor.
And then as the speech therapist who's working
with them, you're able to really
build that sense of rapport and trust with
them.
And so,
you know, it's a bit easier and you
have a little bit more time to devote
to
really giving them a more formal diagnosis
and treatment plan.
But despite all of these positive changes, we
definitely recognize that it's still really hard, and
that's why we're doing this project.
It's hard to differentiate between those motor speech
and language deficits. And Adam kinda touched on
this before, but someone can have aphasia, apraxia,
and dysarthria all at the same time. They
can coexist.
And when that happens, it is difficult to
decipher
which
speech characteristics or symptoms of which disorder.
And sometimes it just involves a process of
elimination.
But in evaluation reports, what we kind of
recommend and we do see often is,
speech therapists will write suspected apraxia of speech
if it's something that, you know, they think
is going is what's going on, but they're
not positive.
And then they kinda list the speech behaviors,
that are observed that align with that diagnosis.
And some of those characteristics might be a
combination of distortion and substitution
errors,
and then abnormal prosody.
And in our experience, a lot of speech
therapists don't
typically,
use prosody as a main defining characteristic,
but we found that that is one of
the main,
defining characteristics of apraxia.
And so with that, you might see a
patient
produce longer words, one syllable at a time
and really segment the syllables,
or they may have long pauses in between
words.
But there are, of course, overlapping characteristics
kinda like I said before.
So for example, you can have distortions in
apraxia of speech and also in dysarthria.
They might be for different reasons, but they
might sound very
similar and that's why this is so hard.
So we rely right now on subjective analysis
without those quantitative tools
to make
or excuse me, to make confident judgments to
differentiate between apraxia, dysarthria,
and aphasia with phonemic paraplegia.
And that's really why we're in need of
some refined definitions
and quantitative assessment tools that help us to
make more confident
diagnostic decisions.
And, ultimately, those those diagnostic decisions are gonna
drive treatment and outcomes for the patients and,
you know, that's what we're so focused on.
And that's kind of where the profile study
really comes in. So, Katerina, you can take
over from here. So the difference in our
approach is we're operating from the assumption that
it's a lot more complex
about,
how how speech is affected after stroke than
these buckets of AOS,
aphasia, with anemic paraphasia,
or dysarthria.
Right? Every patient is different and even within
the syndrome, so, like, say, apraxia of speech,
for example,
they don't all sound the same. There there's
a a lot of qualitative as well as
quantitative
difference.
And we're not looking to develop one single
checklist that you're just gonna
use,
and then identify
one specific
disorder versus another.
We're instead looking at, like, what are the
features that are common after stroke?
What are the things that we're seeing?
And then based on that, we can,
make decisions about clinical care. And one of
the things that we make decisions about potentially
is whether they fit a specific profile,
but they may not. You know? And the
analogy that I like to use is, like,
when we look at aphasia syndromes,
we're all comfortable with the fact that there
are a lot of people that can't be
neatly classified as having one syndrome versus another.
Like,
and we feel like it's the same,
with how speech is affected after stroke. There's
some prototypical cases and then there's some that
are not. So our approach is to measure
the things that make, that are important,
and then look at the patterns that we're
getting,
and then,
use reasoning to differential di lead diagnose
and also to, like, start to think about,
like, what matters for treatment planning. Right?
So we've been at it since 2020
on this project. Oh my goodness. Yeah. It's
it was we got funded right when the
COVID pandemic
started, and we were testing stroke survivors in
hospitals with
face to face. So it was a bit
of a challenge.
But, as I mentioned, we've we've seen,
about 450
people so far.
We've seen 200
matched neuro typical controls as well. So one
of the things we're working on is to
develop norms also
so that,
the the things that we're measuring can be
used by speech pathologists
in their settings.
And we are at a point in this,
project where we have enough
data now that we're starting to disseminate a
lot.
So we have different mechanisms of doing that.
We'll be writing articles. We'll be presenting. We
are going to ASHA next week to do
a,
seminar on on this,
project.
We also have a website that we'll be
sharing tools for, and I think,
we'll talk about that a little bit later.
But
it's really about sharing with the community and
getting feedback from them as well.
Our long term goal is to
really improve intervention.
Okay. It's not to diagnose, just to diagnose.
So we're
very interested
in having,
presentation
profiles that are going to tell us about
the prognosis
and that are going to tell us about
how people might respond to a treatment.
And we are
honestly expecting there to be like a different
classification
system that we're gonna use that's more complex
than the one that's existing
today.
We're already seeing that. And also another,
surprise to us,
honestly was that
because we opened our minds to dysarthria and
like mild dysarthria potentially coexisting, we're finding that
it's quite common in the first few months.
In a grant, you have aims. We have
three aims. The first aim is that we
want to develop a new assessment.
Okay. Because there's not really a good assessment
for speech, after stroke that's doing the things
we want it to do.
So we're developing
speech measures that can capture the features that
commonly occur after stroke and that we can
we can check off.
We're also developing methods where we can assess,
severity
so that we can,
track,
you know, recovery and so that we can
probably link that to intervention methods.
And we wanna do it in a way
that is,
efficient.
You know?
We have people
with speech difficulties after stroke that range from
very severe
to really, really mild, and it doesn't make
any sense to give everybody the same test.
So we're working,
to develop adaptive testing,
where we,
vary the complexity
of words that we present,
and we customize it to the person to
where we can find a level that,
where the person breaks down,
the individual breaks down. And so that's just
a much more efficient way to assess,
severity. And it's also more precise because we
can we can hover around where they're having
difficulties,
and then we can, you know, evaluate how
they're responding to different kinds of cues and
that kind of stuff at that sweet spot,
so to speak.
And then we're also developing several
automated or semiautomated
measures. So in this world now with,
technology and acoustics
and digital,
supports, there's so much that we can do
that we had to do with pen paper
and pencils and just our impressions before.
And Adam will talk more about that. But
our ultimate goal is for these tools to
become
available to everybody.
And right now, we are, we're able to
share some things for research purposes and a
few things for clinicians too, and Adam will
talk about them some more.
But basically, our our whole goal is to,
provide tools that are gonna
be okay for clinicians. So there'll be HIPAA
okay, and there'll be,
also,
very efficient for clinicians
to use to get measures. And so they
don't just have to, like, rely on their
perception and their own judgment immediately.
They can measure things and then look at
what they measured and analyze it.
So that was aim aim one, to develop
a new assessment. It's not gonna be a
paper and pencil assessment. It's gonna be,
a digital one. Like Awesome. Computer based. Probably
web based. Yeah. I I think the tough
part about where we are now is, you
know, we have clinicians that have gone from
paper and pencil to now this fast moving
AI life, and people want instant answers and
put in a speech sample and get this
whole long thing told to them. So
kudos to you guys for trying to
to bridge that gap because I know it's
not an easy one.
We've said yes. So then the main aim
here was to or the first aim anyway
was to develop
a a new assessment.
And we've been using for for years
in using a motor speech exam that had
a number of different words. And usually,
they have some very simple words and some
very difficult words, but there were some shortcomings
in some of the previous lists. And we
wanted to do,
something where we're starting from scratch, really.
And as we developed what we call the
MSE 99, so motor speech exam,
99 for 99 words.
So we were very intentional about including words
that had
a more comprehensive
distribution
of phonetic complexity. So in addition to very
easy and very hard, we have a good
bunch of words in the middle, and that
makes it to where we think that we
can sample,
people a little bit better and and get
a real truer idea of of how
how their speech skill is at a given
time.
So other things that we we we were
very careful about,
sampling phonetic complexity, but we also controlled for
word frequency.
So we're not using obscure
or really uncommon words,
as I've found to be the case in
a lot of previous things. We also try
to exclude words with negative emotional valence.
So while we're doing this, we don't have
to talk about weapons
or anything, like use words with those in
there.
But we originally had a 100 words, and
then we decided to take one off. So
we've got three sets of 33
words.
And right now, essentially, when we
when we get our participants to say the
words, we do them in batches of 33.
And in some of our initial work in
our initial analysis, we're finding that the the
three different subtests,
because they're really well matched,
they look like they're gonna be useful for
parallel forms. So if some person
is given one version one time,
they can get another one the next time
without being concerned about whether there's learning going
on.
So they're matched for complexity and frequency and
even in image ability
of how easily
visualizable
our words are.
But in
the next stage is one of the things
that we're looking at doing and Katharina touched
on this is we want to develop this
into an adaptive test. And so I think
most listeners will be familiar with adaptive
standardized tests like the GREs or the,
the SATs. So if you get a question
correct, the next one's harder. And if you
get a question wrong, the next one's a
little bit easier.
And so with
an adaptive version of the motor speech exam,
if you
say a word, you make an error on
it, you either do,
substitution error or something that's just not quite
right with it,
then the next word will be phonetically a
little bit easier.
And if you keep getting them doing well
on them and producing them correctly, then the
next ones will get harder and harder,
until,
you know, there'll be an algorithm that says,
okay. This is we feel like we have
a good sense of what this person's speech
production ability is.
And we're pretty excited about this. And once
we're complete with this, where this is the
test that we're going to make available to
clinicians
and other researchers
to use.
Excellent.
Mhmm.
Yeah. So those are examples of things that
are going to be
or
there's more, but, like, things that are
for practical applications by SLPs
and also for clinical research. Aim one was
to develop a new assessment. It's digital. It's
a collection of different,
strategies.
Aim two is more about the discovery
and the innovation
here of science. So we are
proposing
that there may be more complexity
than just these buckets of apraxia of speech,
phagia with phonemic, paraphasia, and dysarthria.
And so we're doing exploratory
analysis
of all of the different features that we're
seeing to see what kind of patterns emerge.
We're expecting we've already seen that there's there's
some people that are
difficult to, like, cluster with with with
into a certain profile. But we think that
there's probably meaningful variation,
in terms of both quality and quantity.
And we're we're looking to to discover that
and maybe come up with a a slightly
different classification
system than what we're using today.
Awesome.
That's exciting.
Yeah.
And then that brings me to aim three,
which is
to really
just step back and ask ourselves, why are
we doing the differential diagnosis to begin with?
Like, we've been fighting over, like, what is
apraxia of speech and what is it not
for, you know, hundreds of years. But, ultimately,
it's not really, like, an academic exercise. It's
about are we going to how we're gonna
select the proper treatment.
And given that it's difficult to diagnose
in some cases
that we're we're wondering if maybe there's another
way where we can look at the the
profile of a person
and not necessarily
force them into a category.
Look at the profile and see how that
profile might predict
how they respond to queuing
or how they respond to different types of
intervention
strategies.
And so we're operating under the assumption that
this basic
three part classification
is outdated, maybe.
And,
we're we're hoping to
find how that connects to to treatment responsiveness.
I'll jump in here too.
Adam kinda touched on this with the MSE
99, but,
basically, how the test works is if the
patient,
responds
repeats a word correctly
to a certain word, then they score out
of doing an extra queuing test at the
end.
But if they do not, then they do
have to do a queued,
repetition task.
And that aim has been very exciting to
me to just see,
you know, what patients respond to to what
cues the best, and we don't have those
formal analysis all pulled yet. But even one
example is, you know,
providing a tactile cue to one patient with
maybe a severe apraxia of speech might be
really helpful,
but then providing a tactile cue to someone
with dysarthria might be distracting.
And that's been kind of interesting to see
from a more clinical perspective too. So aim
three
is to determine,
like, what impairment profiles benefit from specific treatments.
And we're here this is the first step.
Right? So we're anticipating
more research in this area.
But just really looking,
with an open mind to see how people
respond to to to treatment,
conditions.
One of the obvious next steps for,
this is to develop,
more dynamic assessment methods
for the clinician where you're really testing different
types of,
treatments, or conditions.
And we are hoping that the profiles that
you're observing quantitatively
also will kind of guide
you to what what kinds of,
treatment conditions you should be,
testing in that dynamic
assessment.
Yeah. So those were our three aims.
And as always, when you do research,
you are getting a lot of answers and
then you have more questions.
And then you realize a lot more research
needs to be done.
But we're we're pretty excited
about it so far.
I think Adam talked about
several
or we talked about some of the measures
that we are using, but
I wonder maybe you could talk a little
bit more about some of the perceptual and
acoustic measures also, Adam. Sure.
Yeah. No. I'd be glad to. And
I think, you know, one of the things
that,
Katarina and I have always tried to apply
a principle in our work to use the
the best or most appropriate tool for whatever
the thing is that we're trying to measure.
And so if there's something that's very easy
and reliable to measure acoustically,
we we do that, and not everything works
that way. And so other things that require
a person to make a judgment or a
rating,
we have well trained teams that work together
to complete those.
And so
part of what we're doing here is figuring
out, okay, well, which which of these measures
will do well to identify different profiles.
And I'll talk a little bit about more
of some of the measures
and maybe a sneak peek at some of
the tools we'll be
developing.
One of the I mean, very simply, one
of the things from the MSE 99 is
we,
are able to have clinicians
do a real time correct or incorrect, thumbs
up, thumbs down, was that word correctly produced.
And in the end, we get a percent
accuracy score on that test.
And and something that we found
so far
that probably is interesting is that there are
some people who do just fine on monosyllabic
and
disyllabic words, but when it comes to
multisyllabic words, that's where they start having
difficulty. And so we will obtain measures of
just correctness,
how correct are they on those words.
And then after that, we start getting into
things that are a little bit more,
you know, we might do some acoustic measurements.
I'll say a little bit about word syllable
duration.
That's something that we've been using for for
a few years. It's a very straightforward
acoustic metric that we can do without
a lot of training or even complicated software.
And so usually what we do is we
measure the length or the duration
of a multisyllabic
word and then divide it by the number
of syllables in the word. So for example,
if we say
a person says the word macaroni
and we measure the duration at one point
four
seconds,
so that that word has four syllables. So
we divide 1.4
by four, and that gives us point three
five
seconds
or three hundred and fifty milliseconds.
And
what we know based on our previous work,
that's a pretty long duration.
So if you take a minute and a
half no. Sorry. A second and a half
to say
macaroni,
that's slower than we expect.
And, you know, anything longer than about
point three two
seconds
or three hundred and twenty milliseconds,
that's
much longer than most neurotypical
talkers would do.
So if they have a really long production
or their their syllables are really long like
that and also they have significant speech sound
distortions,
we might give them an initial classification of
a proxy of speech,
unless there's some other reason that we think
that's not correct.
So word syllable duration is is a big
one that we use, and we think that
that is something that,
a lot of people can measure just on
just on a a simple recording device. You
don't need,
really involved
acoustic software for that.
I wanna jump in there and just say,
like, what why we measure it is, like,
for quantifications,
obviously, to, like, document. But also because when
it is locked, it's kind of slow, but
it's not super duper slow.
We may not recognize it
just through our ears, but we can measure
it. And we can see that this is
definitely longer than than normal. Right? So that
helps diagnose those milder cases.
Thank you. Yeah. And we're we've got
we have a paper out with some norms
on that. So it it gives us a
real idea of a there's a big range
of what neurotypical talkers do, but we can
feel pretty confident that with a long syllable
like that, that that's
beyond what we would expect.
One of the other measures we're looking at
and,
you know, I hope I don't, you know,
give people trauma going back to their speech
science days, but I'll talk a little bit
about voice onset time.
And this is a measure that we use
to differentiate
voice from voiceless
stops.
We basically measure it as the the time
difference between when you release a burst of
air for a stop sound like,
for example,
And then when phonation begins, so for for
the sound, this time interval could be anywhere
from
sixty to
hundred and fifteen milliseconds.
So there's a big range there. I mean,
it's very
short
time,
but it's something that we do automatically. We
don't think about it too much. And
when we think about people who have
speech motor programming difficulty, like somebody with apraxia
of speech or even somebody with dysarthria,
we might expect some of that timing to
break down a little bit.
So one of the things that we're doing
because we have in that 99
word sample of the motor speech exam, there's
a number of words that begin with
a. We have some that begin with g
as well. So k and g, k n
g,
and we're measuring voice onset time of those.
And and mainly the thing that we're looking
at right now is
how consistent are people in that timing.
And right now, it looks like our people
with apraxia of speech have more variable
timing
for the the voice onset time of k,
and, we'll be
working on that more and more,
in the next year or so. We'll be
reporting out on some of that.
And just to say, like, why are we
even doing that? Like,
we were doing that because
we know that voicing is like, that,
there's ambiguity in the voicing when you have
a proxy of speech, especially,
where,
we hear them as distortions. We've documented that.
We hear, like, it's kind of ambiguous as
a voice. Is it voiceless? Voiceless? And it's
difficult,
to, like, evaluate that in the moment as
an speech pathologist.
So what where our goal here is we
do recordings. We do semi automated
analysis. We're not asking SLPs to go and
do, like, these analysis
on their own, but it's gonna be built
into a package that then will
express,
for example, VOT variability for them as a
quantitative measure.
Alongside of that, we we also have a
number of
many people may recognize
that sounds can be difficult. They're they're late
developing in children,
and they're also more difficult to say in
adults with vulnerable speech motor programming abilities.
So one of the other ones we're looking
at that's difficult is fricatives like s and
so
those,
s and s h sounds.
We expect those to be
difficult in some people with apraxia of speech.
And so we're working on some acoustic measurements
for those as well.
And one
measure that's pretty easy to do is how
long does that fricative sound go on? So
measuring the duration of it.
So for most control participants, they might
produce an s between
a hundred and eighty and two hundred and
thirty milliseconds. These are just some initial results
that we have.
But we're finding in people with apraxia and
dysarthria that they
tend to produce longer,
duration of those sounds,
or much longer. So maybe a little longer,
maybe much longer.
And we think that this kind of a
measurement can tell us a little bit about
the timing of articulation,
coordination, and things that we might not pick
up well with our ears. So as Ekaterina
said, if there's some things that are
obvious that we hear, but other things might
be a little bit more subtle. And if
it's easy for us to measure, let's let's
do that.
So while we're while we're capturing the duration
of those fricatives,
the acoustic software can do some more complicated
things and identify which frequencies are stronger in
the signal.
Maybe you can remember that
s kinda has a higher hissy type sound
and s has a more ocean wave kind
of sound, and so there's lower frequencies present.
But when we identify
which frequencies are strongest in the signal, it
can tell us a little bit about articulatory
placement and how consistent somebody is or where
they're placing their tongue for these different sounds.
And so we're
in
the in the middle of doing some of
these analyses. And one of the expectations that
we have is that as we look at
variability of these measures,
this may help to sort out some of
our our groups, whether there's a a subtle
difficulty with speech motor planning
or if there's something that's more obvious.
Well, thanks. This this is awesome. This is
such good stuff. And thank you, Adam. I
don't have too much PTSD from speech science,
so thank you for for putting putting that
lightly,
gently, I should say. Alright.
Anything else we wanna
I I think you guys just wanted to
mention maybe future directions and we can wrap
this up. I think we wanted to talk
a little bit about you know,
we we're really interested I've said this that
we wanna make tools that are
easy to use for people and useful. And
some of the measures we've talked about today,
we'll be developing those into things that are
useful. But we do have a couple of
measures that are already
available.
And,
you know, maybe just as a a sneak
peek to what things might look like in
there, maybe one of the tools that people
will find useful.
We've mentioned how the MSE 99
was developed to to give a balanced
list of words in terms of word complexity.
And and the one of the main metrics
that we use is the word complexity measure
that was developed Carol Stolganin,
for evaluating complexity of child speech.
And it's something that is pretty easy. You
can calculate
the complexity of a word just by knowing,
okay, how many fricatives are there? Are there,
liquid sounds like rhotic, r sounds, or l
sounds? Are there clusters? Are there
velar sounds like k or g.
There's a lot of different rules.
And
to make it a little bit easier, we
created a web app
where you can copy and paste in a
list of words and identify
how
phonetically complex is each one of these
words.
And we use the tool for developing our
99 word list. So we
we were developing okay. Well, like, which words
are we gonna select so that this is
balanced?
But I think it's something that people could
find really useful in their clinical practice.
And,
you know, sometimes people don't know they're choosing
words that are easier.
We we think that some people with difficulty
talking
may avoid,
subconsciously,
they may avoid a word that is a
little bit more difficult. And so,
that word complexity measure app,
I'm interested in in seeing people use it
a little bit more. And,
there's a link from our website for it
in the there's a shortcut version of it,
which is very easy, go.unc.edu/wcmforwordcomplexitymeasure.
So I think that'll be a fun one.
Yeah. As people kind of progress through treatment
too,
we we think about zone of proximal development,
across the the scope of practice. It's like
you wanna give people something that they can
have some success at Yeah. But not so
easy that they're not making any growth. And
so this is something that we think of
as a as a tool where
I mean, even in in children, if you're
doing
we we don't do much work in children
right now. But if you were doing, like,
a a core vocabulary
approach and you come up with a list
of fifty, sixty words a kid is using
at home, well, some of those might naturally
be
really pretty easy to say or low phonetic
complexity
or low word complexity. And then some of
them might be harder in
in something that
can help us to,
grade our our treatment difficulty. What what are
we what are we gonna ask this person
to do today? So I think what she
she had had this this example of endocrinologist,
which is very difficult. And then, yeah, doctor
who treats diabetes,
doctor might be a little there's some difficult
things in there, but, also, that's much easier
to say than endocrinologist.
Yeah. Yeah. So so thank you guys, obviously,
so much for coming on this episode. Let's,
let's just talk about maybe some some future
directions, and and we'll wrap this up.
Yeah.
So we are going to be as we
mentioned before, we're gonna start disseminating a lot
of the stuff that we've learned so far
on this big project.
And then we,
are having,
more questions.
And some of those questions have to do
with,
recovery, like, what kind of prognosis can we
expect based on various types of
information
that we're gathering based on the different profiles
that we're an identifying?
We also wanna look at treatment responsiveness,
so, like, develop more of these dynamic assessments.
We
also are going to need to,
do a bit of
more work to make
or we think that we can make the,
the tools even more accessible
to clinicians. So there's gonna we we need
some engineering, and we need some more,
development or to automate,
the assessment so that it'll be really easy
for a speech language biologists to
to to use with the technology that most
of them have,
in their clinical practice.
And,
I think the another thing that we haven't
talked about today is that we are open
also
to
language
and how language
interacts with speech.
And so we are simultaneously
working out ways to
understand different language profiles
and,
quantify them and see how they
also relate to speech. So,
at our website at aphasia.unc.edu,
one of the resources
or some of the resources that we have
there are also automated,
analysis of,
of, like, connected speech. There are
fairly simple micro level discourse analysis methods
where you have a transcript to copy and
paste it, and you get information that can
help you understand also what words are used,
and in a way that's meaningful for understanding
of aphasia, for example. So
Excellent.
Mhmm. Alright. Awesome. Well, thank you guys both
so much and and, obviously,
Connor as well.
Is she is she we got lost we
lost her in cyberspace, but thank you so
much, Connor. I know she arranged having you
guys come on this podcast. So thank you
so much. This is this is awesome. I,
you know, I I know motor speech is
is not my forte at all, but I
I have so much respect for those of
you that do the work in it. I
know it's incredibly important. I, you know, love
working with patients post stroke. I'm love dysphagia,
but I've I've always said I know that
I'm doing my patients a disservice by not
knowing more about
aphasia, language, motor speech disorders, and how to
treat those kind of things. So thank you
for doing You're not you're not alone to
read. Yeah. Yeah. A lot of people are
frightened about it because it's a big leap
to to see and then do inferencing, and
that's exactly what we we wanna try to
demystify it and make it measurable and Awesome.
So that people will feel feel more comfortable.
Yeah. Yeah. So thank you for doing doing
the the real clinical research. So appreciate that.
So so nice to meet you guys. Thank
you so much for coming on today.
Thank you for having us. It was a
lot of fun.
And that's a wrap for this episode. As
always, thank you so much for listening.
If you'd like to download the show notes
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