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Visi‑Pitch, Model 3950C; Computerized Speech Lab (CSL), Model 4500B

The newly redesigned Visi-Pitch, KAY3950c, and Computerized Speech Lab, KAY4500b, (CSL™) are the next-generation of the products that set the standard in voice and speech capture and analysis. Developed and manufactured as medical devices, Visi-Pitch and CSL are the products of choice for a clinical setting.

The new USB interface on the Visi-Pitch 3950c supports use with laptop computers and provides easy setup. Visi-Pitch also now includes two new software modules; Analysis of Dysphonia in Speech and Voice (ADSV) and iCAPE-V, to compliment the portfolio of eight assessment and biofeedback programs. All software is now Windows 10 compatible.

PENTAX Medical acoustic products offer high-quality recording for accurate representation of patient speech and voice, easy-to-use clinical software with numerous measures of speech and voice quality to support an evidence-based practice, and visual and auditory biofeedback to support acquisition of therapy goals.

Engineered for the human voice

PENTAX Medical acoustic products are specifically engineered to capture disordered voice signals. PENTAX acoustic hardware produces high-quality recordings by providing rigorous signal conditioning and a better signal-to-noise ratio, resulting in accurate representation of the patient's speech and voice.

Supports evidence-based treatment

The built-in protocols of PENTAX Medical acoustic products minimize variability assessment and treatment to improve the accuracy of results and support evidence-based treatment selection.

Improves therapy results

PENTAX Medical Acoustic products supplement standard speech therapy with real-time processing for immediate visual and auditory biofeedback. Studies have shown that the PENTAX Medical Visi-Pitch accelerates patient acquisition of therapy goals.

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Tutorial: Using Visual–Acoustic Biofeedback for Speech Sound Training

Elaine r. hitchcock.

a Montclair State University, NJ

Laura C. Ochs

Michelle t. swartz, megan c. leece.

b Syracuse University, NY

Jonathan L. Preston

Tara mcallister.

c New York University, NY

Associated Data

All data generated or analyzed during this study are included in this published article and its supplemental material files.

This tutorial summarizes current practices using visual–acoustic biofeedback (VAB) treatment to improve speech outcomes for individuals with speech sound difficulties. Clinical strategies will focus on residual distortions of /ɹ/.

Summary evidence related to the characteristics of VAB and the populations that may benefit from this treatment are reviewed. Guidelines are provided for clinicians on how to use VAB with clients to identify and modify their productions to match an acoustic representation. The clinical application of a linear predictive coding spectrum is emphasized.

Successful use of VAB requires several key factors including clinician and client comprehension of the acoustic representation, appropriate acoustic target and template selection, as well as appropriate selection of articulatory strategies, practice schedules, and feedback models to scaffold acquisition of new speech sounds.

Conclusion:

Integrating a VAB component in clinical practice offers additional intervention options for individuals with speech sound difficulties and often facilitates improved speech sound acquisition and generalization outcomes.

Supplemental Material:

https://doi.org/10.23641/asha.21817722

A growing body of research has supported increased clinical use of visual biofeedback tools for remediation of speech sound deviations, particularly distortions affecting American English rhotics ( Bacsfalvi et al., 2007 ; Bernhardt et al., 2005 ; Gibbon & Paterson, 2006 ; Hitchcock et al., 2017 ; McAllister Byun, 2017 ; McAllister Byun & Campbell, 2016 ; McAllister Byun et al., 2014 , 2017 ; McAllister Byun & Hitchcock, 2012 ; Preston et al., 2013 , 2014 ; Schmidt, 2007 ; Shuster et al., 1992 , 1995 ; Sugden et al., 2019 ). Visual biofeedback offers a unique supplement to traditional treatment due to the inclusion of a visual representation of the speech sound, which can be used to make perceptually subtle aspects of speech visible ( Volin, 1998 ). As a result, the learner can alter their speech production by attempting to match a representation of an accurate target displayed in an external image. This tutorial summarizes the literature and describes clinical application of one type of biofeedback, visual–acoustic biofeedback (VAB).

Past research has shown that individuals with speech sound distortions who show a limited response to traditional interventions may benefit from therapy incorporating visual biofeedback (e.g., McAllister Byun & Hitchcock, 2012 ; Preston et al., 2019 ). If the speaker has a poorly defined auditory target, he/she may have difficulty imitating a clinician's auditory model but may succeed in matching a clearly defined visual representation of the target speech sound. Instead of relying on internal self-perception, clients are instructed to use the external image to gain insight into articulatory (i.e., ultrasound and electropalatography) or acoustic (spectrographic/spectral) information that is otherwise difficult to explain or teach. Furthermore, research exploring motor learning in nonspeech tasks has shown increased skill accuracy and less variability when an external focus of attention was incorporated into an oral movement task ( Freedman et al., 2007 ). Thus, adopting an eternal focus of attention for speech movements may enhance retention of learned motor skills ( Maas et al., 2008 ).

Previous literature has devoted considerable attention to types of biofeedback that provide a visual representation of the articulators (e.g., Gibbon et al., 1993 ; Preston et al., 2018 ; Sugden et al., 2019 ). Relatively less attention has been afforded to biofeedback of the visual–acoustic type, which may be more accessible due to the reliance on just an acoustic signal. This tutorial will briefly review the concepts of resonance and formants, define the characteristics of VAB, and describe different types of acoustic biofeedback. We will emphasize the use of a linear predictive coding (LPC) spectrum, as it is the most commonly used form of VAB in the research literature to date. We will briefly summarize several populations that may benefit from VAB. We will then describe its use for children with speech sound disorders, specifically rhotic errors, followed by an example of how to implement treatment ( McAllister Byun, 2017 ; McAllister Byun & Hitchcock, 2012 ; McAllister Byun et al., 2014 , 2016 ). Lastly, as an example of clinical utility, we will provide a detailed description of rhotic acquisition training using VAB while integrating specific cuing strategies described in previous literature focused on traditional approaches to /ɹ/ treatment ( Preston et al., 2020 ). This tutorial will demonstrate how clients can be taught to identify and modify their productions to match an acoustic representation or formant pattern that characterizes the speech target. We offer guidelines for intervention using VAB with the long-term goal of improving outcomes for challenging speech sound distortions.

Unlike other forms of visual biofeedback that reveal articulatory actions, VAB depicts an acoustic representation of the speech sound, such as an LPC spectrum or spectrogram, which will be discussed in further detail in the following sections (see Figure 1 for an example using an LPC spectrum). The client and clinician together view a real-time dynamic image of the speech signal simultaneously paired with a template representing the acoustic characteristics of the target sound. The client can be cued to adjust their speech output to match a preselected template or target on the screen (see Figure 2 ), which can be paired with cues for articulator placement. By watching the visual display change in response to their articulatory changes, learners can build stronger associations between articulatory postures and auditory-acoustic outcomes ( Awan, 2013 ). At the same time, because different articulatory configurations can yield similar auditory and acoustic consequences, VAB allows the learner to find their own articulatory approach to a given target sound. This level of flexibility may be beneficial in the context of sounds like /ɹ/ ( McAllister Byun et al., 2014 ), which can be realized with a range of articulatory configurations, as detailed below.

Sample linear predictive coding (LPC) spectrum showing oral and pharyngeal cavity during production of /i/ (“ee”). We have labeled F3 for clarity; however, the locations of F1 and F2 are typically sufficient for identifying vowels.

Sample linear predictive coding (LPC) spectrum of /i/ with target template.

Resonance and Formants

Briefly summarized, resonance occurs when the molecules of air in the vocal tract vibrate in response to the sound source, namely, vibratory behavior of the vocal folds. Depending on the size and shape of the supraglottic cavities (pharyngeal and oral cavities), specific frequencies will be amplified or attenuated ( Ladefoged, 1996 ). Formants are those frequencies that are amplified because they align with the natural resonant frequencies of the vocal tract ( Fant, 1960 ). In general, a large cavity volume will resonate at a low frequency, whereas a small cavity volume will resonate at a high frequency ( Zemlin, 1998 ). In a simplified two-container model of vocal tract resonance, the size and shape of the pharyngeal and oral cavities determine the first (F1) and second (F2) formant frequencies, respectively. The frequency of F1 is determined primarily by tongue body height (vertical plane), which affects the volume of the pharyngeal cavity. Specifically, the pharyngeal cavity will contain a large volume of air when the tongue is high in the mouth, pulling the tongue root up and out of the pharyngeal space; its volume is smaller when the tongue body is lower. This results in low F1 for a high vowel (e.g., /i/) and higher F1 values for a low vowel (e.g., /ɑ/; Peterson & Barney, 1952 ). The frequency of F2 is determined by tongue position in the anterior–posterior plane, which affects the volume of the oral cavity in front of the point of maximal tongue constriction. When the tongue is anterior in the mouth (as in /i/ or /e/), this space is small, resulting in a high F2; when the tongue is posterior (as in /u/ or /o/), this space is larger, resulting in a low F2. Thus, a high front vowel such as /i/ is characterized by a low F1 and a high F2 (see Figure 1 ). When a speaker is attempting to produce an /ɹ/ sound, more complex acoustic dynamics are at play. F1 and F2 are typically located in a neutral or central position of the vowel space, similar to their position for schwa. The acoustic hallmark of an accurate /ɹ/ production is a low third formant (F3), which is associated with supraglottic vocal tract constrictions at the lips, anterior oral cavity, and pharyngeal region ( Chiba & Kajiyama, 1941 ). Constrictions in these regions can be formed with a range of tongue configurations, as we describe in more detail below ( Delattre & Freeman, 1968 ; Tiede et al., 2004 ; Zhou et al., 2008 ). In this context, speakers must learn what configuration of their own articulatory structures best maps to the auditory-acoustic signature of /ɹ/ (e.g., Guenther et al., 1998 ). Displaying acoustic information may be particularly useful in order to allow exploration of articulatory-acoustic mappings in a therapeutic context.

LPC Spectrum Versus Spectrogram

Altering the shape of the vocal tract changes its resonant characteristics, which in turn changes the frequency of the formants. We can visualize these frequency changes in various forms, most notably with an LPC spectrum or spectrogram (see Figure 1 ). When viewing an LPC spectrum, frequency, typically measured in Hertz (Hz), is represented on the x -axis whereas amplitude, typically measured in decibels (dB), is represented on the y -axis. An LPC spectrum allows visualization of the amplitude of the frequency components of a speech sound; formants or resonant frequencies of the vocal tract are visualized as vertical peaks in the frequency range of the spectrum. Traditional LPC spectra do not include a time axis, thus reflecting a static image of selected point in time within a speech sound. However, current technologies allow for display of dynamic, real-time components of the changing LPC spectrum. In several existing software programs for acoustic analysis, speakers may view changing formant values as moving peaks corresponding to articulatory modification of the vocal tract (see Supplemental Material S1 ).

In comparison, a spectrogram allows the learner to visualize the relative amplitudes of all frequency components of a sound, with time represented on the x -axis and frequency on the y -axis. The amplitude of different frequency components is represented with gradations of color or darkness. The formant frequencies, which are characterized by high amplitude, appear as dark horizontal bands that shift up and down with the changing resonances of the moving vocal tract (see Figure 3 ). This display of acoustic information can be used in a clinical context to teach clients to modify their speech sounds by seeing changes in format patterns ( Shuster et al., 1995 ).

Spectrogram showing an adult speaker production of “ear.” The shifting formants are reflected in the changing horizontal bands.

Who Can Benefit From VAB?

Several populations, including second language learners, individuals who are hard of hearing, and individuals who have been diagnosed with speech sound disorder, are uniquely suited to benefit from spectrographic or spectral VAB due to the nature of the target adopted in therapy or training ( Akahane-Yamada et al., 1998 ; Brady et al., 2016 ; Carey, 2004 ; Crawford, 2007 ; Dowd et al., 1998 ; Ertmer & Maki, 2000 ; Ertmer et al., 1996 ; Kartushina et al., 2015 , 2016 ; Li et al., 2019 ; Maki & Streff, 1978 ; Olson, 2014 ; Stark, 1971 ). These populations demonstrate speech characteristics that warrant an initial focus on the segmental aspects of speech (vowels/consonants). A visual–acoustic intervention program can be effective when targeting sonorant speech sounds, where the speaker's attempts can be lengthened and compared with a preselected target or template. While fricatives and suprasegmental factors (intonation, stress, and duration) may also be identified as potential targets for which different types of VAB are appropriate ( Swartz et al., 2018 ; Utianski et al., 2020 ), such approaches are beyond the scope of this tutorial. Last, our anecdotal observations suggest that individuals age 8 years or older tend to benefit most from VAB, presumably because VAB requires that the client can comprehend a dynamic visual display and connect that display with their articulatory changes, a task that can be challenging for younger children. However, it is possible that some younger children may benefit this technique. Careful consideration of factors such as attention and motivation may be more important than age when determining candidacy for potential VAB clients.

Individuals With Hearing Loss

Several studies have suggested that spectrographic biofeedback can be successfully utilized as a speech training tool for individuals who are deaf or hard of hearing (see Table 1 ; Crawford, 2007 ; Ertmer & Maki, 2000 ; Ertmer et al., 1996 ; Maki & Streff, 1978 ; Stark, 1971 ). It is well known that the severity of hearing loss impacts intelligibility of speech. Furthermore, children with severe–profound hearing loss often demonstrate poorer speech intelligibility compared with children with mild–moderate hearing loss. Speakers who are deaf or hard of hearing may experience challenges with segmental aspects of speech production (consonants, vowels, and diphthongs) and suprasegmental aspects of speech ( Culbertson & Kricos, 2002 ).

Selected studies using visual–acoustic biofeedback (VAB) for speech training outside the context of speech sound disorder.

Note.  M = male; F = female; HoH = hard of hearing; L2 = second language clients; LPC = linear predictive coding.

In children with hearing loss, the use of VAB can compensate for reduced auditory access to the full range of the speech spectrum. VAB offsets the lack of salient auditory cues by providing visual representations of the speech signals. VAB circumvents an impaired auditory feedback mechanism, instead allowing the client to “see” what happens to the target sound in response to articulatory changes during training of vowels ( Ertmer et al., 1996 ; Maki & Streff, 1978 ; Stark, 1971 ) and/or consonants ( Ertmer & Maki, 2000 ; Shuster et al., 1992 ).

Second Language Learners

Research incorporating various forms of VAB (LPC spectra, spectrograms, and vowel charts) has been successfully implemented in speech training programs with adult learners who aim to master speech sounds in a second language or L2 ( Akahane-Yamada et al., 1998 ; Brady et al., 2016 ; Carey, 2004 ; Dowd et al., 1998 ; Kartushina et al., 2015 , 2016 ; Li et al., 2019 ; Olson, 2014 ). A number of studies have shown progress in the acquisition of L2 speech sounds after a relatively short period of VAB training (see Table 1 ).

Children With Speech Sound Disorders

A growing body of research suggests that technology-enhanced interventions such as VAB could improve outcomes for children with challenging speech sound distortions, notably distortions of /ɹ/ (see Table 2 for a detailed list of studies); we will draw on the example of rhotic biofeedback throughout this tutorial as a demonstration of clinical application of VAB. American English rhotics are among the most frequently misarticulated sounds and are widely acknowledged as some of the hardest to treat, often proving resistant to traditional therapy techniques ( Ruscello, 1995 ; Shuster et al., 1995 ). 1 In the following sections, we will summarize the articulatory complexity of the /ɹ/ sound and explain the unique benefits of VAB for this population.

Summary of visual–acoustic biofeedback (VAB) studies in the context of speech sound disorder.

Note.  CII = cumulative intervention intensity; M = male; F = female; LPC = linear predictive coding; NR = not reported.

Articulation of American English rhotics. Both the high prevalence and treatment-resistant nature of American English rhotic errors are commonly attributed to the articulatory complexity of an accurate production ( Gick et al., 2007 ). Typically, /ɹ/ is produced with two major lingual constrictions, one anterior and one posterior in the vocal tract (e.g., Delattre & Freeman, 1968 ). The posterior constriction is characterized by tongue root retraction to narrow the pharyngeal cavity ( Boyce, 2015 ). Numerous investigations have shown that the anterior tongue configuration for /ɹ/ is subject to variability, both across and within speakers ( Delattre & Freeman, 1968 ; Tiede et al., 2004 ; Zhou et al., 2008 ). Two major variants are commonly reported: the retroflex variant of /ɹ/, where the tongue tip is raised and may be curled up slightly at a point near the alveolar ridge, and the bunched variant of /ɹ/, where the tongue tip is lowered and the anterior tongue body is raised to approximate the palate. However, there is a great deal of variability between these extremes, and some tongue shapes do not fit well into either category ( Boyce, 2015 ). An added complication is that many speakers use different tongue shapes across different phonetic contexts ( Mielke et al., 2016 ; Stavness et al., 2012 ). Many speakers also produce /ɹ/ with slight labial constriction ( King & Ferragne, 2020 ). Importantly, the various articulatory configurations for /ɹ/ appear to result in relatively consistent acoustic patterns at the level of the first three formants and are, to the best of our knowledge, perceptually equivalent ( Zhou et al., 2008 ).

In summary, treatment for misarticulation of /ɹ/ involves cueing the learner to imitate tongue constrictions that are complex and vary across speakers and contexts, making it hard for the clinician to know which rhotic variant to cue. It poses a further challenge because the crucial tongue constrictions are contained within the oral cavity and, as such, cannot be visualized without some form of instrumentation. Finally, because /ɹ/ is produced with limited contact between articulators, there is little tactile feedback to support learners in achieving the desired tongue configurations. Although, in some cases, traditional motor-based treatment strategies can successfully help remediate rhotic errors (see Preston et al., 2020 , for a full discussion), it is common for clients to demonstrate limited progress, which may result in frustration or even termination of treatment ( Ruscello, 1995 ).

VAB for American English rhotics. Regardless of the articulatory complexity of the American English /ɹ/, the sound that is produced yields a distinctive formant pattern that makes it particularly suitable for treatment with VAB. A lowered third formant (F3), occasionally low enough that it appears to merge with the second formant (F2), is considered the hallmark of American English /ɹ/ (e.g., Boyce & Espy-Wilson, 1997 ). In contrast, distortions of /ɹ/ are characterized by F3 values between 2500 and 3500 Hz, compared with correct /ɹ/ productions typically lower than 2500 Hz for children and 2000 Hz for adults ( Campbell et al., 2017 ; Lee et al., 1999 ; Shriberg et al., 2001 ). Figure 4 shows the close spacing of F2 and F3 in an LPC spectrum of syllabic /ɹ/. With VAB, clinicians can use the stable acoustic signature of /ɹ/ to help the client identify the movements of the tongue that result in acoustic changes in the direction of a more accurate /ɹ/ sound.

Linear predictive coding (LPC) spectrum and spectrogram of adult correct /ɹ/ generated in the Sona-Match module of the Computerized Speech Lab (PENTAX Medical, Model 4500).

As noted above, because /ɹ/ can be produced with many different articulatory postures (e.g., bunched and retroflex), it can be challenging to identify optimal articulatory positions for some clients. Thus, the fact that VAB emphasizes the acoustic target rather than a specific tongue configuration represents a particular strength in the context of treatment for /ɹ/ misarticulation. Instead, the clinician is free to select any cues and feedback that they judge will help the client get closer to the desired acoustic characteristics of /ɹ/ ( McAllister Byun et al., 2016 ). As we describe below, however, we recommend pairing visual feedback with articulatory cues focused on achieving an adequate oral constriction, lowering the tongue dorsum/body, elevating the lateral margins of the tongue, retracting the tongue root into the pharyngeal cavity, and achieving slight lip constriction (see Preston et al., 2020 , for details). The opportunity to observe incremental acoustic changes in connection with their articulatory adjustments can help clients acquire motor routines for postures that offer little tactile or kinesthetic feedback ( McAllister Byun & Hitchcock, 2012 ).

Not only does the articulatory complexity of /ɹ/ make it a difficult sound to remediate when produced in error, but many children presenting with /ɹ/ misarticulations also lack the auditory acuity to recognize rhotic errors in their own speech. Shuster (1998) reported that children with /ɹ/ misarticulation showed a decreased ability to discriminate correct versus distorted /ɹ/ sounds in their own output, making it harder to benefit from treatment in which the clinician supplies an auditory model of the target sound and prompts the child to match it. Similar results were reported by Cialdella et al. (2021) and Hitchcock et al. (2020) , whose findings showed that typically developing children demonstrated more consistent classification of items along a synthetic continuum from /ɹ/ - /w/ compared with children with rhotic speech errors.

Evidence base for VAB in treatment of rhotic misarticulation. Both spectrograms and LPC spectra depict the formants or resonant frequencies of the vocal tract, which appear as horizontal bars in the former and vertical peaks in the latter. The early visual–acoustic literature focused on the use of spectrograms to teach clients to recognize and attempt to match the formant pattern characterizing a target sound ( Shuster et al., 1992 ; Shuster et al., 1995 ). More recent research has focused on the use of real-time LPC spectra generated either with Sona-Match or staRt software, described below. While both a spectrogram and LPC spectrum display formant information, recent studies have favored the use of the LPC spectrum as the acoustic biofeedback modality, because the display is visually less complicated than a spectrogram and, as a result, potentially less challenging for children to interpret changing formant patterns (see Figure 4 ).

Early case studies using spectrograms provided meaningful foundational evidence for the use of VAB in the treatment of /ɹ/ for children with speech sound disorder. Shuster et al. (1992 , 1995) found that spectrograms can be used by clinicians to support effective intervention for residual rhotic misarticulation. They reported successful implementation of a spectrographic biofeedback program for three individuals with speech sound disorder, ages 10, 14, and 18 years. In these two small-scale studies, participants were described as nonresponders after receiving at least 2 years of traditional articulation treatment. Before the start of VAB intervention, all participants demonstrated 0% accuracy in /ɹ/ productions. After two to six sessions of spectrographic biofeedback intervention, all participants had attained at least 70% correct productions of isolated sustained /ɹ/. By the 11th session, all participants were producing /ɹ/ in isolation and rhotic diphthongs with 80%–100% accuracy. Generalization to spontaneous conversation and sentence-level utterances was reported for the 10- and 14-year-old participants, respectively ( Shuster et al., 1995 ).

Recently, several small-scale experimental studies have indicated that VAB real-time LPC spectra can also represent an effective form of intervention for residual /ɹ/ distortions ( McAllister Byun, 2017 ; McAllister Byun & Campbell, 2016 ; McAllister Byun & Hitchcock, 2012 ; McAllister Byun et al., 2016 ). McAllister Byun and Hitchcock (2012) investigated the efficacy of VAB using a single-case experimental design in which participants were transitioned from traditional motor-based treatment to spectral biofeedback in a staggered fashion after 4–6 weeks. They found that eight of 11 participants (ages 6;0–11;9 [years;months]) showed clinically significant improvement over the 10-week course of treatment and, in six of these eight participants, gains were observed only after the transition to VAB treatment. In another single-case experimental study, McAllister Byun et al. (2016) found that six of nine participants with residual rhotic errors demonstrated sustained improvement on at least one treated rhotic target after 8 weeks of VAB, despite previously showing no success over months to years of traditional articulatory intervention. A subsequent single-case experimental study of 11 children who received both traditional and biofeedback treatment in a counterbalanced order ( McAllister Byun & Campbell, 2016 ) revealed a significant interaction between treatment condition and order, such that individuals who received a period of VAB followed by a period of traditional treatment showed significantly greater accuracy on generalization probes than individuals who received the same treatments in the reverse order. McAllister Byun (2017) conducted a single-case randomization study in which seven participants received both spectral biofeedback and traditional treatment in an alternating fashion over 10 weeks of treatment. In that study, three participants showed significantly greater within-session gains in biofeedback than traditional sessions, with no participant showing a significant difference in the opposite direction ( McAllister Byun, 2017 ). Peterson et al. (2022) used a similar single-case randomization design in a study of treatment using staRt biofeedback software (described below) via telepractice. In that study, all four participants made substantial gains in rhotic production accuracy, and one participant showed a significant advantage for biofeedback over traditional treatment (although interpretation of this result was complicated by the fact that random assignment resulted in a concentration of biofeedback sessions in the early stages of treatment). Finally, Benway et al. (2021) treated 9- to 16-year-old children with /ɹ/ errors using both VAB and ultrasound biofeedback in an alternating fashion and found that five of seven children showed evidence of acquiring /ɹ/. Only one participant showed a significant difference in within-session acquisition of /ɹ/ between the two treatment types, and this participant showed an advantage for VAB compared with ultrasound sessions. Overall, findings from these studies indicate that VAB intervention programs using an LPC spectrum can have positive outcomes for children with residual distortions of /ɹ/ who have not responded to traditional intervention approaches.

The remainder of this tutorial will provide suggested guidelines for the use of VAB to encourage acquisition of North American English /ɹ/. We will provide details on how to set an appropriate target, how to orient learners to the VAB display, how to integrate specific articulatory cueing strategies developed in the context of traditional treatment ( Preston et al., 2020 ), and how to deploy these cues in accordance with the principles of speech-motor learning ( Maas et al., 2008 ) to encourage generalization across speech contexts.

Selecting an Appropriate LPC Target Pattern

VAB requires a target or template representing the desired acoustic output that the client can attempt to match during their practice productions. However, the same target cannot be used for all clients because formant frequencies are influenced by vocal tract size. 2 That is, the placement of the individual formant peaks represented on the LPC spectrum differs depending on the size of the vocal tract, although the ratio of the distance between the peaks remains roughly the same (see Figure 5 ). Thus, the best target for a client would be selected from a typical speaker who is approximately the same age, size, and sex. Once the client begins to establish an approximation of a perceptually acceptable rhotic production, the clinician may choose to adjust the target (e.g., replacing a target derived from a different speaker with a target generated from the client's best approximation). A client's formant pattern targets may be refined over time as the client's rhotic accuracy improves, providing visual evidence of a progression toward age-appropriate production. Alternatively, the original target from a different speaker may be retained throughout the duration of treatment.

Adult and child correct linear predictive coding (LPC) spectrum or /ɹ/.

In the Computerized Speech Lab (CSL), Sona-Match module ( PENTAX Medical, 2019 , Model 4500), the LPC spectrum has three different viewing/window settings: child, adult female, and adult male. Selection is generally based upon the age and gender of the individual receiving the intervention (see Supplemental Material S2 ). The target used in VAB is a template or trace representing a snapshot of the spectral envelope of the entire formant signature for /ɹ/ (see Figure 2 and Supplemental Material S2 ). That is, although the focus in VAB for /ɹ/ is on the location (peak) of F3 and the distance between F2 and F3, a peak representing F1 is also visible in the target. Templates are not provided by default by the manufacturer; however, templates created by our team are available at Open Science Framework ( https://osf.io/kj4z2/ ). By contrast, in the staRt app ( McAllister Byun et al., 2017 ; BITS Lab NYU, 2020 ), the target takes the form of a single adjustable slider that is intended to represent the center frequency of F3, with the goal of drawing the client's attention to this critical peak in the display. When a user creates a profile on the staRt app, a target frequency is automatically generated based on the age and gender entered. The target is drawn from normative data representing typically developing children's productions of /ɹ/ ( Lee et al., 1999 ). Users of the staRt app are instructed that they can adjust the slider as desired, but that target values below 1500 Hz are not recommended (see Figure 6 ).

Image of staRt app ( BITS Lab NYU, 2020 ). Used with permission..

Establishing Comprehension of Acoustic-Articulatory Connection

Prior to initiating treatment, a key factor for success is the inclusion of one to two introductory sessions to ensure that the client understands how lingual movements modify the vocal tract and how those changes can be visualized via alterations of the formant peaks in the LPC spectrum. The potential for improvement may be compromised if the acoustic information in the LPC spectrum is not interpretable to the learner. To offset this possibility, an introductory session prior to the initiation of detailed practice is beneficial to provide an explanation of the biofeedback spectrum. In this session, the clinician should demonstrate how lingual movements are reflected in the changing formant pattern using maximally opposing vowels, such as /i/ and /ɑ/ to optimize the differences in the ratio of formant peaks (see Figure 7 ). Once the client has observed the clinical demonstration, they are encouraged to move their tongue around in their mouth while observing how their lingual movements shift the formants (“peaks” or “bumps”) when different sounds are produced. A verbal comprehension check is recommended prior to moving forward to the treatment phase to ensure that the client adequately understands the relationship between articulatory changes and formant patterns. A version of the script used in our current clinical research using the CSL Sona-Match is included in Appendix A . (Interested clinicians may access a video example of an introduction to VAB located in our Supplemental Material S3 ). The staRt app has an interactive tutorial intended to guide the client and clinician through this basic information (as well as information about the acoustics of /ɹ/, described below); a video narration of the staRt tutorial is included in Supplemental Material S4 .

Linear predictive coding (LPC) images comparing /i/ (“ee”) and /a/ (“ah”).

Characteristics of Spectral Changes During Articulatory Exploration

Once basic comprehension of the relationship between articulator changes and acoustic outputs is established, clients can then be familiarized with the concept of matching formant templates in a task involving sounds that they can articulate accurately. One strategy is to present the client with an unidentified vowel template and then direct them to guess which vowel the template represents. 3 The client may be asked to produce several different vowels suggested by the clinician and then look for the LPC spectrum that is the closest match to the vowel template. Following several successful matches, the client is typically ready to progress to the next phase of treatment targeting rhotic productions.

Maximal benefit from spectral biofeedback stems from the client's ability to interpret changing formant patterns in real time. Initially, it is recommended that the clinician provide an age-appropriate verbal explanation of the formants, specifically highlighting that F2 and F3 (the second and third “bumps” or “peaks”) are far apart in an incorrect /ɹ/ sound but move close together or merge in correct /ɹ/ production (see Figure 8 for an example of an LPC spectrum for incorrect and correct /ɹ/). A comprehension check where the client is asked to verbally describe the visual properties of correct and incorrect /ɹ/ as reflected in the LPC spectrum and/or select an image depicting the requested target is helpful prior to initiating biofeedback treatment. Either static or dynamic images may be used; see Supplemental Material S5 for a teaching example of a transition from incorrect to correct /ɹ/ production. Once they have been familiarized with the acoustic characteristics of correct and incorrect /ɹ/, participants can be presented with an appropriate rhotic template superimposed over the dynamic LPC spectrum and encouraged to match the pattern of the formant peaks by modifying their vocal tract configurations. During treatment, the lowering of F3 may initially be a slight or gradual change, but learners can begin to associate this with a successive approximation of the target, enabling them to recognize when their productions are getting closer.

Comparison of correct and incorrect /ɹ/ productions.

Articulatory Cues for Rhotic Sounds

While learners using biofeedback can be given general encouragement to explore a wide range of vocal tract shapes in an effort to achieve a closer match with the formant template, it is often judged clinically useful to pair the spectral biofeedback image with specific cues for articulator placement. Because part of the rationale for adopting biofeedback comes from its ability to engender an external direction of attentional focus, which has been associated with improved learning outcomes in nonspeech motor tasks ( Maas et al., 2008 ), there is a possible theoretical argument whereby biofeedback could be rendered less effective through the incorporation of articulator placement cues that direct the learner's attention inward. This question was investigated in the work of McAllister Byun et al. (2016) , in which all participants received VAB treatment, half with explicit cues for articulator placement and half whose cues only referenced the visual–acoustic display. There were no significant differences in outcomes between the two attentional focus conditions, and the authors concluded that providers of VAB could incorporate any cues they judge clinically useful, including articulator placement cues. Recall that American English rhotics are typically characterized by three vocal tract constrictions: in the lips, anterior oral cavity, and posterior pharyngeal cavity ( Delattre & Freeman, 1968 ), with the latter accompanied by lateral bracing and posterior tongue body lowering. Viewing the LPC spectrum while simultaneously shaping the child's production via articulator placement cues can help determine which combination of elements to focus on in treatment and scaffold the accuracy of novel tongue movements that differ from the existing habituated, yet off-target, motor plan. For example, some speakers produce /l/ with pharyngeal constriction, so shaping from /l/ may scaffold production of a necessary element for /ɹ/ ( Shriberg, 1975 ). The clinician can suggest an articulator placement cue with a direct reference to the LPC spectrum (e.g., “Try moving your tongue back and watch what happens to the wave”). For a detailed list of articulator placement cues and shaping strategies for American English /ɹ/, see the work of Preston et al. (2020) . Although Preston et al. (2020) focuses on traditional (i.e., nonbiofeedback) treatment, clinicians are encouraged to incorporate the same strategies as articulator placement cues during delivery of VAB.

Goal Selection

The American English rhotic phoneme /ɹ/ can occur in different positions in the syllable, including prevocalic position as in red , syllable nucleus as in her , and postvocalic position (sometimes described as the offglide of a rhotic diphthong) as in deer and door. These positional variants have slightly different acoustic and articulatory characteristics ( McGowan et al., 2004 ), and identifying which one to target first is a clinically important question. We suggest initially selecting a stressed syllabic /ɝ/ for several reasons. From a developmental perspective, there is reason to believe that vocalic targets emerge earlier in typically developing speakers, which suggests that vocalic /ɝ/ may also be likely to emerge in treatment before other variants ( Klein et al., 2013 ; McGowan et al., 2004 ). Additionally, syllabic /ɝ/ has been shown to have a longer duration relative to /ɹ/ in a syllable onset position (e.g., road , tray ). This longer duration generally makes it easier for a client to identify target formant peaks using the LPC spectrum. However, it is also possible that a client may demonstrate an optimal response to /ɹ/ in postvocalic position (e.g., care, fear, and car ), particularly when the offglide is influenced in a facilitative way by the phonetic context of the preceding vowel. For example, the clients who struggle to form a constriction in the pharyngeal region when attempting a rhotic production may have more success in postvocalic context following a low back vowel (e.g., /ɑ/) due to the facilitative nature of the neighboring articulatory context ( Boyce, 2015 ), which could justify selecting “are” as an early target as well. Therefore, clinicians are encouraged to carefully assess several contexts that may be facilitative for each learner.

Suggested Outline of a Visual–Acoustic Treatment Session Using LPC Spectra

Prepractice. Treatment sessions are usually initiated following one to two introductory sessions explaining production of /ɹ/ and the connection to the LPC spectrum, as outlined previously. Each session begins with a relatively unstructured prepractice period in which clients are encouraged to explore a variety of articulatory combinations to try to align their spectrum with a preselected template. Initially, guidance to explore the lingual and labial movement may be offered without reference to specific articulators (e.g., “While you are looking at the image on the screen < clinician points to spectral peaks on the computer screen >, try to move your tongue around in your mouth to make the peaks or bumps change. It may not sound like an /ɹ/ right away, but that's okay for now”). Clinicians provide general encouragement and then systematically begin to suggest specific articulatory cues to facilitate acoustic and perceptual changes. Introduction of articulator cues may be spaced out over time (e.g., limited to one type of articulatory cue used throughout the duration of a session) in order to limit cognitive load. Alternatively, cues may be grouped together within a session. Next, the clinician and the client review the dynamic LPC image to determine the impact of a given cue on the spectral shape. Additional articulatory cues (e.g., raise the tongue blade, lower the tongue dorsum, and retract the tongue root) can be added as the child becomes more comfortable understanding formant peaks. The articulatory cues found to facilitate the most change during prepractice can form the focus of subsequent structured practice trials.

The prepractice period involves relatively unstructured, highly interactive elicitation of targets to help the client begin to connect movements of the articulators with changes in the acoustic waveform. In the early acquisition phase of learning, we recommend that prepractice comprise a relatively large percentage of the total session time (e.g., roughly 50% or 20–25 min in a 50-min session) and elicit a limited range of /ɹ/ targets. In this early phase, prepractice may include several different syllables containing /ɹ/, selected depending on the individualized needs of each client. In our current research studies (e.g., McAllister et al., 2020 ), we select one stimulus item from each of the five target /ɹ/ variants, beginning with elicitation of /ɝ/ (see Goal Selection for more details). The clinician should work to elicit each target using verbal models, VAB, and articulator placement cues. In our research, we advance to the next target within prepractice when the client has produced the target 3 times in a fully correct fashion or completed 10 unsuccessful attempts, whichever comes first. Prepractice may be terminated after (a) a set number of trials or time duration or (b) a set number of correct productions of the selected target variants. As treatment advances, the prepractice duration may decrease if the client accurately produces the selected target variants at least 3 times; for instance, the duration could be reduced from approximately 50% to 10% (5 min of a 50-min session). The /ɹ/ variants selected in prepractice are typically carried over into the period of structured practice that follows.

Structured practice. A period of high-intensity structured practice typically follows the prepractice phase of treatment. Previous literature investigating the efficacy of VAB intervention for residual /ɹ/ distortions has varied in the intensity of treatment with respect to session frequency, session duration, and number of trials elicited per session (see Table 2 ). Given the recent evidence of the importance of dosage in biofeedback treatment ( Hitchcock et al., 2019 ; Peterson et al., 2022 ), we recommend targeting 100–150 trials at a minimum.

One challenge widely acknowledged in the context of biofeedback treatment (e.g., Gibbon & Paterson, 2006 ; McAllister Byun & Hitchcock, 2012 ) is the possibility that new skills learned in treatment may not generalize to a context in which biofeedback is not available. Once the client establishes an accurate /ɹ/ production, we recommend structuring practice to maximize generalization of the newly acquired sound. In particular, we recommend that the main duration of the session should emphasize production of the target rhotic contexts at a stage of complexity where accuracy is achievable but not too difficult or too easy, also known as an optimal challenge point level ( Guadagnoli & Lee, 2004 ). This can be operationalized as the level where the client can achieve 50%–80% accuracy within the treatment setting. In our clinical research, we offer adaptive difficulty in structured practice using the Challenge Point Program (CPP; McAllister et al., 2021 ), a free and open source PC-based software that encodes a structured version of a challenge point hierarchy ( Matthews et al., 2021 ; Rvachew & Brosseau-Lapre, 2012 ) for /ɹ/ practice. 4 The CPP was designed to make it feasible for clinicians to elicit multiple treatment trials while adaptively increasing or decreasing task difficulty based on within-session performance. The adaptive behavior of the CPP is determined by three within-session parameters adjusted on a rotating schedule (see Appendix B ). The parameters alter the functional task difficulty by changing the frequency with which biofeedback is made available, the mode of elicitation (e.g., imitation vs. independent reading), and the complexity of target productions presented (e.g., syllables, words, and phrases) based on the participant's accuracy over 10 trials. If accuracy is 80% or better, the CPP adjusts one parameter to increase difficulty in the next block. If accuracy again reaches or exceeds 80%, another manipulation is added to further increase difficulty. If accuracy falls at or below 50%, these manipulations are withdrawn in reverse order of application to reduce difficulty. As a result, biofeedback is faded and the production task becomes progressively more challenging as client accuracy improves. Further detail on the nature of CPP can be found in the work of McAllister et al. (2021) .

Another significant consideration for clinicians adopting VAB comes from evidence that biofeedback strategies may be most effective during the early acquisition stages of speech learning ( Fletcher et al., 1991 ; Gibbon & Paterson, 2006 ; Preston et al., 2018 , 2019 ; Volin, 1998 ). The premise that VAB may be most effective for establishing new motor patterns is consistent with the broader body of research investigating principles of motor skill learning. Certain parameters of practice have proved more facilitative of the initial acquisition of a motor plan, whereas other practice conditions may maximize retention and transfer (see review in Maas et al., 2008 ). Qualitative knowledge of performance feedback, defined in this context as feedback that helps the speaker identify how a sound was produced, seems to offer the greatest advantage for the client when the motor task is novel or the nature of the target is unclear to the client ( Newell et al., 1990 ). In later phases of learning, detailed knowledge of performance feedback has been reported to be less effective and potentially even detrimental to learning. On the other hand, knowledge of results feedback, defined as identifying if a sound was produced correctly or incorrectly, has been shown to be most effective in later phases of learning ( Maas et al., 2008 ). Regardless, a critical element of feedback is that it is always based on the clinician's judgment of the accuracy of how the production sounds, which should be prioritized over the “correctness” of the acoustic display image. That is, VAB is a tool for generating a perceptually correct sounding /ɹ/. Matching a template is not explicitly the goal if it does not result in a production that sounds correct. An expert clinician's perception of the child's attempt should determine the accuracy of the production, which, ideally, is supported by the visual display.

Emphasizing the identification of formant peak changes secondary to articulatory alterations during sound acquisition can be considered knowledge of performance feedback, given the correlation between the behavior (articulatory movements) and the resulting visual change (altered formant peaks). Therefore, the principles of motor skill learning suggest that biofeedback is likely to be most effective in the earliest stages of learning, and its utility may decline over time as the learner becomes more proficient ( McAllister Byun & Campbell, 2016 ; Peterson et al., 2022 ; Preston et al., 2018 ). In keeping with this theoretical framing, two separate studies including both traditional and biofeedback treatment in similar counterbalanced study designs reported a measurable advantage when biofeedback was provided prior to traditional treatment ( McAllister Byun & Campbell, 2016 ; Preston et al., 2019 ).

Computer Monitor Sight Line

Several additional factors may influence the efficacy of biofeedback treatment. For example, it is crucial for clients to view the screen image during attempts to modify their articulatory behaviors. While this may seem obvious, in our experience, many clients tend to look toward the clinician when being given directions. As a result, they are not watching the screen for related changes in the dynamic image. This may limit the client's ability to connect articulatory movements with formant changes reflected in the LPC spectrum, necessitating redirection to focus on the screen. Frequent redirection may be necessary to maintain focus on the visual display, particularly for younger clients or clients with comorbid diagnoses such as attention-deficit/hyperactivity disorder. Because repetitive reminders may increase client frustration, we suggest framing the learning task so the child has an active role in monitoring the visual output (e.g., after each trial, the child describes what they saw on the visual display with specific reference to the movement of the “bumps”).

Client Posture

We also recommend that the client is seated in a fully upright position when viewing the screen image. A lowered chin typically limits the range of articulatory movement, potentially limiting the child's ability to alter existing articulatory behaviors. Additionally, slouching limits thoracic volume for respiratory support during phonation. This can result in a low-intensity or distorted acoustic signal, which may result in limited or absent peaks on the LPC spectrum. Raising the table height or the computer monitor may mitigate these situations and optimize learning opportunities.

In order to maximize the accuracy of the LPC spectrum representing the client's /ɹ/ production, it is important to achieve a good signal-to-noise ratio. In this scenario, the signal is the client's voice compared with the level of background noise. The strength of this input signal will be influenced by the device used for voice recording. While it is possible to use the sound card on a computer, we recommend using a dedicated external microphone for the best signal-to-noise ratio. There are several types of directional patterns for microphones, including omnidirectional and unidirectional. In general, a unidirectional microphone is preferable to an omnidirectional microphone, because it is less likely to pick up unwanted background sound. However, when using a unidirectional microphone, it is important to remain attentive to the distance and angle between the client's mouth and the microphone. The optimal mouth-to-microphone distance may vary across speakers and devices, but we recommend testing different distances until a clear signal is achieved and then encouraging the client to remain at that distance as consistently as possible.

VAB offers several unique benefits compared with other forms of visual biofeedback. It is the least invasive form of biofeedback, requiring only a microphone and a computer screen. Other visualization technologies used to facilitate acquisition of speech targets require direct contact with the speech structures (for instance, ultrasound requires direct skin contact via a probe held beneath the chin, and electropalatography requires intraoral placement of the pseudopalate used to register and display areas of linguopalatal contact; Bernhardt et al., 2003 ; Dagenais et al., 1994 ; Hitchcock et al., 2017 ; McAllister Byun et al., 2014 ; Preston et al., 2013 ). VAB also tends to be the least expensive biofeedback technique. As noted previously, some software for acoustic analysis and speech visualization programs can be downloaded at little or no cost (e.g., staRt). Clinical software programs such as Sona-Speech (PENTAX Medical) are not free but are typically less costly than the hardware required for articulatory types of biofeedback such as ultrasound. Last, the lack of additional hardware other than an external microphone also renders VAB more amenable to delivery via telepractice compared with other visual biofeedback techniques, thus increasing the treatment delivery options available via telepractice in speech pathology. For further discussion of the use of VAB via telepractice, see the work of Peterson et al. (2022) .

It is sometimes suggested that VAB may be harder for clients and clinicians to interpret because formant patterns are more abstract than a direct display of articulator shape or contacts. However, there is a lack of evidence directly investigating this question of ease of interpretation across biofeedback types. As noted above, the only published evidence directly comparing the two types of biofeedback (VAB and ultrasound) reported one participant with a slight advantage for VAB over ultrasound, with the remaining six participants showing no significant difference between conditions ( Benway et al., 2021 ).

Conclusions

The use of visual biofeedback to treat individuals with speech sound errors who show a limited response to traditional interventions has grown significantly over the past 30 years. The authors' collective findings demonstrate that VAB can facilitate perceptually and acoustically correct rhotic production in children with whose residual distortions of /ɹ/ have not responded to traditional methods of intervention (e.g., McAllister Byun & Hitchcock, 2012 ; Peterson et al., 2022 ). The largely successful outcomes of these studies, as well as the evidence of successful use of VAB with L2 learners (e.g., Li et al., 2019 ) and individuals with hearing loss (e.g., Ertmer & Maki, 2000 ), demonstrate the potential for spectral/spectrographic displays to help learners effectively alter their own speech production patterns.

The suggested strategies for using VAB proposed in this tutorial are based on approximately 10 years of research experience by the authors. Our suggested course of treatment includes a clear introductory phase to familiarize the client with the technology, an acquisition phase marked by intensive VAB use, and a generalization phase in which the use of VAB is faded while target complexity is simultaneously increased. While not all of the strategies recommended here have been the subject of rigorous experimental manipulations, each has been refined over the course of numerous research studies. In summary, the strategies offered here may serve as a guideline for clinicians planning to incorporate the use of visual–acoustic technology into their clinical toolbox. Increased clinical adoption of VAB may facilitate improved outcomes for clients with a range of different speech goals.

Author Contributions

Elaine R. Hitchcock: Conceptualization (Lead), Writing – original draft (Lead), Writing – review & editing (Lead), Visualization (Equal). Laura C. Ochs: Conceptualization (Equal), Writing – original draft (Equal), Writing – review & editing (Equal), Visualization (Equal). Michelle T. Swartz: Project administration (Supporting), Writing – original draft, Writing – review & editing (Supporting). Megan C. Leece: Project administration (Supporting), Resources (Equal), Visualization (Equal), Writing – review & editing (Supporting). Jonathan L. Preston: Project administration (Equal), Writing – original draft (Equal), Writing – review & editing (Equal). Tara McAllister: Funding acquisition (Lead), Project administration (Lead), Writing – original draft (Equal), Writing – review & editing (Equal).

Data Availability Statement

Supplementary material, supplemental material s1, supplemental material s2, supplemental material s3, supplemental material s4, supplemental material s5, acknowledgments.

Research reported in this publication was supported by National Institute on Deafness and Other Communication Disorders Grant R15DC019775 (principal investigator: E. Hitchcock) and R01DC017476 (principal investigator: T. McAllister). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors gratefully acknowledge Roberta Lazarus, Sarah Granquist, Nina Benway, Lynne Harris, and Samantha Ayala for their vital contributions as clinical partners in this study.

Introduction to Visual–Acoustic Biofeedback With Vowels

Within-Session Levels in the Challenge Point Program (CPP) Software (McAllister et al., 2021)

Note.  Parameters (represented in columns) change on a rotating basis between levels; the parameter that was changed in a given level is in bold.

Funding Statement

Research reported in this publication was supported by National Institute on Deafness and Other Communication Disorders Grant R15DC019775 (principal investigator: E. Hitchcock) and R01DC017476 (principal investigator: T. McAllister). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

1 Distortions of /s/ represent another common clinical challenge and are also amenable to remediation with VAB. However, here, we focus on /ɹ/, because it is much better represented than /s/ in the literature to date.

2 Selecting a target template is dependent upon the VAB software program. Regardless of the software selections, we suggest that clinicians first determine the approximate location of the third formant. Note that the location of F3 in a misarticulated /ɹ/ is expected to be somewhere around 3500 in a younger child (9 years old and under) and 3000 in an older child (10 years and up). In a correct /ɹ/, F3 is expected to be somewhere around 2000 Hz (see Lee et al., 1999 , for detailed breakdown by age level).

3 As indicated previously, vowel templates are dependent on the VAB software program. Clinicians may also create and save additional vowel templates (directions provided in the SonaMatch User Manual) keeping in mind that the target template should be generated from a speaker who is relatively well matched for vocal tract size.

4 The CPP is available at http://blog.umd.edu/cpp/download/ .

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Visi Pitch Model 3950C Computerized Speech Lab (CSL) Model 4500B

Product details:.

• Dimension (L*W*H) 13 x 9 x 5 inches
• Product Type List No.- r
• Use Assessment and treatment of speech and voice disorders
• Power 110-240V
• Properties Accurate pitch tracking, real-time display, and various analysis capabilities
• Color Code Typically varies by model, often gray or black
• Suitable For peech-language pathologists, audiologists, and researchers
• Click to View more
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Visi Pitch Model 3950C Computerized Speech Lab (CSL) Model 4500B Price And Quantity

• Price 5000000 INR/Piece
• Minimum Order Quantity 01 Piece

Visi Pitch Model 3950C Computerized Speech Lab (CSL) Model 4500B Product Specifications

• Material Electronic components, plastic, and metal housing
• Weight Approx. 5 lbs
• Application Voice and speech analysis for clinical and research purposes

Visi Pitch Model 3950C Computerized Speech Lab (CSL) Model 4500B Trade Information

• Main Domestic Market All India

Product Description

Product Description :- Model 3950C provides real-time pitch extraction and analysis, aiding in the assessment and treatment of speech disorders. It offers precise measurements of fundamental frequency, intensity, and other vocal parameters. The CSL Model 4500B is a high-performance system for detailed acoustic analysis, phonetic research, and clinical diagnostics. It features advanced signal processing capabilities and a user-friendly interface, making it ideal for speech-language pathologists, researchers, and clinicians aiming to analyze and improve vocal performance. Both models are essential for detailed and accurate speech analysis in clinical and research settings.

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Computerized Speech Lab CSL

Jan 19, 2012

240 likes | 2.87k Views

Computerized Speech Lab (CSL)-Model 4500. The computerized Speech Lab is the Leading Hardware/Software System for Speech and Voice Professionals, developed by Kay Electronics Corporation of New Jersey.. . Hardware Description. The device is an input/output recording device, which works in collaboration with a PCThe CSL compiles with the specifications and features needed for reliable acoustic measurements. It includes PCI hardware interfaceIdeal for speech analysisThe CSL offers input9460

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1. Computerized Speech Lab (CSL) Karen Hawkins

2. Computerized Speech Lab (CSL)-Model 4500 The computerized Speech Lab is the Leading Hardware/Software System for Speech and Voice Professionals, developed by Kay Electronics Corporation of New Jersey.

3. Hardware Description The device is an input/output recording device, which works in collaboration with a PC The CSL compiles with the specifications and features needed for reliable acoustic measurements. It includes PCI hardware interface Ideal for speech analysis The CSL offers input signal-to-noise performance 20-30db greater than that of generic plug-in sound card counterparts.

4. Software Options Current CSL, Model 4500 and 4150, software and database options include:

5. Software Options Current CSL, Model 4500 and 4150, software and database options include:

6. The Device Abbreviated Specifications Analog Inputs: 4 channels: two XLR and two phono-type, 5mV-10.5V peak-to-peak, channels 3 and 4, switchable AC or DC coupling, calibrated input, adjustable gain range >38dB, 24-bit A/D, Sampling rates: 8000-200,000Hz, THD+N: <-90dB F.S., Frequency Response (AC coupled): 20 to 22kHz +.05dB at 44.1kHz� Digital Interface: AES/EBU or S/P DIF format, transformer-coupled Software Interface: ASIO and MME Computer Interface: PCI (version 2.2-compliant), PCI card; 5.0� H x 7.4� W x 0.75� D (half-sized PCI card) Computer Requirements: Windows XP/Windows 2000, one free PCI slot, >800MHz Pentium III Analog Output: 4 channels, line and speaker, headphone output, channels 1 and 2 provide line &speaker outputs Physical: 4� W x 8.25� H x 12.5� D, 4 lbs. 12 oz., 45 watts, speaker, and microphone (Shure SM-48 or equivalent, XLR-type)

7. Examples of Speech Analysis

8. What Is It? CSL is the leading speech analysis system for acoustic phonetics, speech language pathology, voice science, laryngology, language training, bioacoustics, and forensic acoustics. It achieved this leadership and reputation by providing the most comprehensive features, professional-level hardware, extensive databases, and the best product support in the field.

9. Tell Me More! CSL is an extremely powerful yet very easy to use system for obtaining and analyzing speech signals. Vocal input can be read and stored at rates of up to 51,200 samples per second, providing detailed information to the clinician or researcher on a variety of speech parameters, including pitch, timing and energy.

10. Guess What? As you speak, this information is displayed graphically on the computer screen, providing immediate, easily-understood visual feedback to both subject and technician.  These speech parameters can be used in the diagnosis and treatment of voice disorders, as an aid to language learning and accent reduction, and by speech researchers.

11. Lastly! Speech analysis has been used for teaching,research, voice measurements, clinical feedback, acoustic phonetics, second language articulation, and forensic work. Contains nineteen optional programs and databases target specific speech applications. CSL provides the necessary features and specifications for efficient, easy, accurate and repeatable recording and measurement of speech signals for speech professionals.

12. Company Contact Information Kay Elemetrics Corp. 2 Bridgewater Lane v Lincoln Park, NJ 07035-1488 USA Tel: 1-800-289-5297 (USA and Canada) v (973) 628-6200 v Fax: (973) 628-6363 E-mail: [email protected] v Web: www.kayelemetrics.com

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Respiratory muscle training in stroke patients with respiratory muscle weakness, dysphagia, and dysarthria – a prospective randomized trial

Editor(s): Zhang., Qinhong

a Department of Physical Medicine and Rehabilitation

b Department of Neurology

c Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Department of Respiratory Therapy, Chang Gung Memorial Hospital Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

∗Correspondence: Meng-Chih Lin, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital Kaohsiung Medical Center, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Niao-Sung District, Kaohsiung 83305, Taiwan (e-mail: [email protected] ).

Abbreviations: APQ = amplitude perturbation quotient, ERMT = expiratory respiratory muscle training, FAS = fatigue assessment scale, FEV1 = forced expiratory volume in first second, FOIS = functional oral intake scale, FVC = forced vital capacity, IRMT = inspiratory respiratory muscle training, Jitt = jitter percent, MEP = maximal expiratory pressure, MIP = maximal inspiratory pressure, MMEF = maximum mid-expiratory flow, MRS = Modified Rankin scale, PPQ = pitch perturbation quotient, RAP = relative average perturbation, RMT = respiratory muscle training, ShdB = shimmer in dB, Shim = shimmer percent, VTI = voice turbulence index.

How to cite this article: Liaw MY, Hsu CH, Leong CP, Liao CY, Wang LY, Lu CH, Lin MC. Respiratory muscle training in stroke patients with respiratory muscle weakness, dysphagia, and dysarthria - a prospective randomized trial. Medicine . 2020;99:10(e19337).

The study was approved by the Institutional Review Board of the Chang Gung Memorial Hospital, Kaohsiung Medical Board (IRB number: 105-1989C).

This research was funded by Chang Gung Memorial Hospital, Taiwan (grant number: CMRPG8E0911; 2016-5-1 to 2018-4-30).

The authors report no conflicts of interest.

The devices used are as follows: Model 4500 (Multi–Dimensional Voice) for Dimensional Voice Program, Model 5105 (KayPENTAX), Computerized Speech Lab (CSL).

Dofin Breathing Trainer (a threshold trainer), (DT 11 GaleMed Corporation), (DT 14 GaleMed Corporation). Product number: PO09000038.

Pulmonary function tests: spirometer (Vitalograph, Serial Spirotrac, Buckingham, USA).

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

Objective: 

To examine the efficacy of combined inspiratory and expiratory respiratory muscle training (RMT) with respect to the swallowing function, pulmonary function, functional performance, and dysarthria in patients with stroke.

Design: 

Prospective, randomized controlled trial.

Setting: 

Tertiary hospital.

Participants: 

The trial included 21 subjects (12 men, 9 women) aged 35 to 80 years presenting with 6 months history of unilateral stroke, respiratory muscle weakness (≥70% predicted maximal inspiratory pressure (MIP) and/or ≤70% maximal expiratory pressure (MEP)), dysphagia, or dysarthria. These subjects were randomly assigned to the control (n = 10, rehabilitation) and experimental (n = 11, rehabilitation with RMT) groups.

Intervention: 

Inspiratory RMT starting from 30% to 60% of MIP and expiratory RMT starting from 15% to 75% of MEP for 5 days/week for 6 weeks.

Main outcome measures: 

MIP, MEP, pulmonary function, peak cough flow, perception of dyspnea, Fatigue Assessment Scale, Modified Rankin Scale, Brunnstrom stage, Barthel index, Functional Oral Intake Scale (FOIS), and parameters of voice analysis.

Results: 

Significant differences were observed between both groups in terms of MIP, forced vital capacity (FVC), and forced expiratory volume per second (FEV1) of the percentage predicted. Significant difference was found with respect to the change in fatigue, shimmer percent, amplitude perturbation quotient, and voice turbulence index (VTI) according to the acoustic analysis in the RMT group. The FEV1/FVC ratio was negatively correlated with jitter percent, relative average perturbation, pitch perturbation quotient, and VTI; the maximum mid-expiratory flow (MMEF) and MMEF% were also negatively correlated with VTI. Significant differences among participants of the same group were observed while comparing the Brunnstrom stage before and after training of the affected limbs and the Barthel scale and FOIS scores in both the groups.

Conclusions: 

Altogether, 6-week combined inspiratory and expiratory RMT is feasible as adjuvant therapy for stroke patients to improve fatigue level, respiratory muscle strength, lung volume, respiratory flow, and dysarthria.

Clinical trial registration number (Clinical Trial Identifier): NCT03491111.

In the article, “Respiratory muscle training in stroke patients with respiratory muscle weakness, dysphagia, and dysarthria – a prospective randomized trial” 1 , which appears in Volume 99, Issue 10 of Medicine , in the second paragraph of the introduction “>90%” should be “<90%.” In that same paragraph, force expiratory flow should be forced expiratory flow.

Table 7 appeared twice as Tables 7 and 8. The correct Table 8 appears below.

Medicine. 99(17):e20194, April 2020.

1 Introduction

Stroke patients often experience respiratory muscle weakness, swallowing disturbances, [1–3] decreased peak expiratory flow, blunted reflexive cough, impaired voluntary cough, [4] impairment of the cardiorespiratory fitness, [5] and voice dysfunction in dysarthria. [6]

An 8-week inspiratory muscle training (IMT) can increase the inspiratory muscle strength and endurance in chronic stroke patients with > 90% of predicted maximal inspiratory pressure (MIP), [7] while a 6-week IMT can increase the forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), vital capacity, force expiratory flow rate 25% to 75%, and maximal voluntary ventilation in patients with unilateral stroke during the previous 12 months; this finding was also correlated with the exercise capacity, sensation of dyspnea, and quality of life. [8] Expiratory muscle training (EMT) can improve the MIP and peak expiratory flow rate in stroke patients [2] and improve the voice aerodynamics, [9] MEP, and swallowing ability, in acute stroke patients along with reducing vallecular residue and penetration-aspiration. [3]

Messaggi-Sartor et al reported that 3-week IMT of patients with 30% MIP and EMT of patients with 30% MEP could improve the inspiratory and expiratory muscle strength and potentially reduce the occurrence of respiratory complications at 6 months after the onset of acute stroke. [10] Furthermore, Guillen-Sola et al reported that 3-week inspiratory/expiratory muscle training could improve inspiratory and expiratory muscle strength and swallowing function. [11] However, the efficacy of combined IMT and EMT in subacute stroke patients (within 6 months) with respiratory muscle weakness, swallowing disturbance, and dysarthria has not been reported.

Respiration and swallowing require the activation of common anatomical structures. EMT can facilitate the contraction of submental muscles, elevate the hyolaryngeal complex, [12,13] pull the hyoid bone in the anterior-superior direction, and invert the epiglottis towards the pharynx during swallowing. [14–16] Dysarthria (including wet voice) and dysphagia have similar pathogeneses in stroke patients, especially those related to the laryngopharyngeal functions. [17] The acoustic change in phonation following a swallow is a high-risk indicator of fluid aspiration. [18] Moreover, the subglottal pressure initiates and maintains the vocal fold vibration that facilitates voice production.

Five-week EMT followed by 6 sessions of traditional voice therapy increased the subglottal pressure leading to a higher vocal intensity and increased voice dynamic range in professional voice users. [9] Meanwhile, a multi-dimensional voice program (MDVP) is suitable for voice analysis in dysarthria associated with various neurologic diseases of different severity, [6] and the MDVP Model 5105 (KayPENTAX) is reliable and advanced for speech analysis and acquisition. [19]

We hypothesized that the repetitive resistance, pressure, and force generated by threshold RMT could improve the respiratory muscle strength, swallowing function, and voice quality via sensory stimulation and motor activation of the oropharynx and respiratory muscles. RMT can also assist in the upregulation of reflex cough. [2] To our knowledge, this is the first follow-up study that investigated the feasibility and efficacy of a combined IMT and EMT with respect to pulmonary dysfunction, swallowing dysfunction, voice dysfunction due to dysarthria, and activities of daily living of subacute stroke patients.

2.1 Participants and setting

This prospective, single-blinded, randomized controlled study was conducted in a tertiary hospital from April 2016 to October 2018 with 47 unilateral stroke patients aged 35 to 80 years with respiratory muscle weakness, swallowing disturbance, or dysarthria for 6 months. The patients were screened by attending physicians and randomly divided into the control (conventional rehabilitation) and experimental (rehabilitation with RMT) groups by a research assistant using a random number generator algorithm. Signed informed consent from the patients or a family member was obtained, and the Institutional Review Board approved the study.

Sixteen subjects declined to participate, not meeting the inclusion criteria regarding inspiratory and expiratory muscle weakness (≥70% predicted MIP and/or ≤ predicted MEP). [20,21] In addition, patients with increased intracranial pressure, uncontrolled hypertension, decompensated heart failure, unstable angina, recent myocardial infarction, complicated arrhythmias, pneumothorax, bullae/blebs in the preceding 3 months, severe cognitive function or infection, recurrent stroke, brain stem stroke, and aphasia were excluded.

Each patient underwent physical and neurological examination, and assessment of clinical characteristics, height, weight, body mass index, duration of stroke, Modified Rankin scale (MRS), Brunnstrom stage, hand grip of unaffected upper limb, Barthel activity of daily living index, spirometry, peak cough flow, MIP, MEP, resting heart rate, perception of dyspnea using modified Borg scale, [22] resting oxyhemoglobin saturation, fatigue assessment scale (FAS), [23] functional oral intake scale (FOIS), [24] and voice quality. [18] These parameters were recorded before and after the 6-week RMT. The technician was blinded to the group allocation.

2.2 Intervention

Patients were trained using the Dofin Breathing Trainer (DT 11 or DT 14 GaleMed Corporation), a hand-held threshold trainer with a spring-loaded valve and a colored ball that indicates whether breathing strength exceeds the set target pressure. Ten training levels were set for IMT and EMT. The DT11 has a pressure range of 5 to 39 cmH 2 O during inspiration and 4 to 33 cmH 2 O during expiration, while DT14 has a pressure range of 5 to 79 cmH 2 O during inspiration and 4 to 82 cmH 2 O during expiration.

For IMT, the subjects were instructed to tightly seal their lips around the breathing trainer with a nose clip in a sitting position, and inhale deep and forceful breathes that were sufficient for opening the valve with a whistling sound (due to the movement of the colored ball inside the trainer). Then, they were instructed to exhale slowly and gently through the mouthpiece. The inspiratory training pressure ranged from 30% to 60% of each individual's MIP for 6 sets of 5 repetitions. For EMT, the subjects were instructed to blow fast and forcefully which could open the valve following maximal inhalation. Expiration training pressure commenced from 15% to 75% of threshold load of an individual's MEP for 5 sets of 5 repetitions, 1 to 2 times per day, 5 days a week for 6 weeks [2,25,26] ; 1 to 2 minutes of rest was allowed between each set.

The training resistance was adjusted according to tolerance. We requested the patients to stop if they experienced discomfort and, in case of desaturation, the threshold load was decreased. The patients were called once a week for checking their compliance with the program and were encouraged to continue with it. A training diary was provided for them to keep a record.

In addition to RMT, both the groups underwent the regular rehabilitation, which included postural training, breathing control, improving cough technique, checking chest wall mobility, fatigue management, orofacial exercises, thermal-tactile stimulation, Mendelsohn maneuvering, effort swallowing, or supra-glottic maneuver among others.

2.3 Main outcome measurement

The primary outcome variables were: change in MIP (cmH 2 O) and MEP (cmH 2 O). For MIP, negative pressure is favorable and for MEP, positive pressure is favorable. The secondary outcome variables were the pulmonary functional parameters including FVC (liter), FVC (% prediction), FEV1 (liter), FEV1 (% of prediction), FEV1/FVC (%), maximum mid-expiratory flow (MMEF) (liter/s), MMEF%, peak cough flow (liter/s), resting heart rate, resting respiratory rate, FOIS [7-point scale, from 1 (nothing by mouth) to 7 (total oral diet with no restrictions)], [24] Modified Borg scale (0.5 to 10), [22] FAS (10-item, 5 levels (1: never to 5: always), score: 10 to 50), [23] non-affected hand grip strength, Barthel index (0 to 100), [27] MRS (5: severe disability to 0: no symptoms), [28] and the variables of acoustic analysis.

Pulmonary function test: Pulmonary function was assessed using a spirometer (Vitalograph, Serial Spirotrac, Buckingham, VA) as per the American Thoracic Society standards. [29] MIP and MEP: MIP was measured after maximal expiration near residual volume. MEP was measured after maximal inspiration near total lung capacity while patients were sitting and wearing a nose-clip in an upright position. All pressure measurements were maintained for at least 1 second. The highest recorded value was used for calculations only when two technically satisfactory measurements were obtained. [30,31]

Voice quality analysis: Voice quality was assessed with the Computerized Speech Lab (CSL), Model 4500 (Multi-Dimensional Voice). The participant was asked to phonate the vowel ‘a’ at their most comfortable speaking pitch and loudness for at least 3 seconds while sitting at a 30 cm distance from the microphone. The lowest pitch and highest pitch with increasing and decreasing loudness were measured. [6] The parameters of voice analysis included jitter percent (Jitt), relative average perturbation (RAP), and pitch perturbation quotient (PPQ) for frequency perturbation. Amplitude was determined based on the shimmer in decibels (ShdB), shimmer percent (Shim), amplitude perturbation quotient (APQ), and peak-to-peak amplitude variation, while the noise-related parameters included noise-to-harmonic ratio and voice turbulence index (VTI). [6]

2.4 Sample size calculation

Based on the study by Sutbeyaz et al, [8] the mean differences of MIP between experimental group and control group before and after IMT training were fixed at 7.87 cmH 2 O and 2.90 cmH 2 O, respectively, with standard deviation of 6.6 cmH 2 O and 1.9 cmH 2 O. After calculation, we realized that the study required at least 17 subjects in each group. While setting these conditions at a two-sided significance level at 0.05 with a statistical power of 0.80, the number of subjects in each group should be 24 under the estimation that the dropout rate was about 30%. Number of participants in the RMT group to that in the control group was set at 1:1 ratio.

2.5 Data analysis

Values were expressed as the mean ± standard deviation for continuous variables and number (%) for categorical variables. Linear regression analysis was used to adjust for sex, BMI, and the Brunnstrom stage of the distal part of the affected upper limb. Clinical characteristics were compared using the Mann–Whitney U test for continuous variables and the Fisher exact test for categorical variables. The Wilcoxon signed-rank test was used to examine the change in clinical data from baseline in both the groups, and the Mann-Whitney U test was applied for comparisons between the groups. The Spearman rank correlation coefficient was calculated to analyze the correlations between cardiopulmonary function parameters and clinical characteristics. All collected data were analyzed using the SPSS Statistics version 22.0 software (IBM, Armonk, NY). P value < .05 was considered statistically significant.

A total of 47 patients were determined to be eligible initially. After exclusion of 16 patients, 31 were randomly allocated to the RMT (15 patients) and control (16 patients) groups. During training, 10 patients (32.2%) dropped out of the study, 5 from the RMT group (reasons being: they lived far away from the study venue, insisted to stay at home or in the nursing home, and had impaired vision in one eye and upper gastrointestinal bleeding) and 5 from the control group (reasons being: 4 patients did not undergo follow-up at the outpatient department and 1 patient had another disease). Finally, 21 patients completed the study (RMT group, n = 10; control group, n = 11) ( Fig. 1 ). The Intention-To-Treat and Per Protocol analysis for all the data is shown in Tables 1 and 2 .

No statistically significant difference between the groups was noted in the clinical characteristics, cardiopulmonary function, and acoustic analysis parameters ( Tables 1–3 ), except sex ( P = .036), height (training vs control group: 1.58 ± 0.08 vs 1.68 ± 0.08 cm, P = .011), body mass index (BMI) (26.0 ± 3.7 vs 21.82 ± 2.29, P = .011 kg/m 2 ) ( Table 1 ), and Brunnstrom stage of the distal part of affected upper extremity (3.10 ± 0.99 vs 2.18 ± 0.75, P = .021) ( Table 2 ).

Significant correlations were found between MIP and MEP (r = 0.632, P < .01); peak cough and MEP (r = 0.504, P < .05), FVC (r = 0.781, P < .01), and FEV1 (r = 0.739, P < .01); Borg scale and MEP (r = −0.505, P < .05); age and FVC (r = −0.536, P < .05), FEV1 (r = −0.590, P < .01), and MMEF (r = −0.584, P < .01); post-stroke duration and FVC (% predicted) (r = 0.594, P < .01), FEV1 (% predicted) (r = 0.458, P < .05), and FEV1/FVC (% predicted) (r = −0.456, P < .05) ( Table 4 ).

Significant differences within each group were noted for the change from baseline of the Brunnstrom stage of the affected upper and lower limbs, Barthel scale, and FOIS. However, no significant difference between the groups was observed ( Table 5 ). Significant change from the baseline was seen in fatigue ( P = .007) ( Table 5 ), MIP ( P = .008) only in the RMT group, and significant between-group differences were seen for MIP ( P = .001), FVC ( P = .017), and FEV1 (% predicted) ( P = .047) according to the linear regression analysis adjusted for the differences already present between the groups in terms of sex, BMI, and Brunnstrom stage of the distal part of affected limb ( Table 6 ).

Regarding voice analysis, there were significant changes among participants of the RMT group in the Shim ( P = .043), APQ ( P = .036), and VTI ( P = .025) values ( Table 7 ). Significant negative correlations were found between FEV1/FVC and Jitt (r = −0.574, P < .05), RAP (r = −0.574, P < .05), PPQ (r = −0.538, P < .05), and VTI (r = −0.835, P < .01). MMEF (r = −0.659, P < .05) and MMEF% (r = −0.692, P < .05) were negatively correlated with VTI ( Table 8 ).

4 Discussion

Both RMT and control groups showed significant changes from the baseline in Brunnstrom stage of the affected limb, Barthel index, and FOIS; the stroke duration positively correlated with FVC and FEV1 (% prediction) and negatively correlated with FEV1/FVC%. These findings can be partially explained by neurologic recovery with time and the effectiveness of regular rehabilitation after stroke onset.

Significant changes in MIP, MEP, and fatigue level from baseline were observed only in the RMT group. However, the linear regression analysis, adjusted for between-group differences in sex, BMI, and Brunnstrom stage of the affected limb, demonstrated significant between-group differences in the change from baseline in mean MIP, FVC, and FEV1 (% predicted). Furthermore, a significant mean change from baseline of MEP was found only in the RMT group. The mean MEP positively correlated with MIP and peak cough flow, which in turn positively correlated with FVC and FEV1; MEP also negatively correlated with the Borg scale. These findings indicate that the 6-week combined RMT could improve the respiratory muscle strength patients. The effect of RMT on MIP was apparently greater than that observed on MEP.

Clinically, the discoordination between inhaling and exhaling should be resolved at the beginning of RMT and the active inspiratory volume needs to be enough for forceful expiration or cough flow. This explains why a significant between-group difference was seen only in MIP and not in MEP or peak cough as a 6-week program may be too short to achieve a significant effect on expiratory muscle force. This finding was consistent with results of a systemic review, which showed that RMT shows greater improvement in MIP, but has no effect on MEP in patients with various neurologic diseases. [32] Further, 5-week EMT for ischemic stroke patients increases the average expiratory muscle strength by approximately 30 cmH 2 O and improves the urge and strength of reflex cough, but is not effective for voluntary cough or swallow function. Therefore, the efficacy of EMT was attributed to the upregulation of reflex cough. [2] Moreover, a 4-week RMT by using threshold resistance device in acute stroke patients significantly improved the mean MIP by 14 cmH 2 O, MEP by 15 cmH 2 O, and the peak expiratory flow rate (74 L/min) of all three groups, regardless of the allocation of expiratory, inspiratory, or sham training; but no between-group differences was noted. [33] Similarly, our study showed no significant between-group difference in MEP and peak cough flow. Furthermore, our study also revealed no difference between both groups in terms of MRS, hand grip strength, and FOIS, which may be attributed to the heterogeneity in neurological lesion characteristics and existence of multiple comorbidities including congestive heart failure, atrial fibrillation, hypertension, and diabetes mellitus. Most of our participants’ brain lesions were located in the middle cerebral artery territory. Moreover, quite a few participants had borderline cardiomegaly or congestive heart.

The physical activity level in stroke patients is usually limited by fatigue and dyspnea. Some patients were too fatigued to attend the program at the time of eligibility screening. However, our RMT group patients showed a significant change from baseline of FAS in contrast to that in the control group.

For stroke patients, the perception of dyspnea is low and blunted, which is due to their dissociation between respiratory effort and dyspnea. [34] This can explain the similar Borg scale scores of both groups.

Regarding voice signals, Shim and ShdB are associated with hoarse and breathy voices; APQ and PPQ indicate the inability of the cords to support a periodic vibration. Hoarse and breathy voices usually have increased APQ, PPQ, or RAP. [19] Moreover, the subglottal pressure initiates and maintains the vocal fold vibration and voice production. Wingate et al reported that 5-week EMT followed by 6 sessions of traditional voice therapy could increase subglottal pressure, which increased the vocal intensity and voice dynamic range. [9] After the 6-week RMT, our stroke patients showed significant changes in Shim, APQ, and VTI from baseline in the voice analysis thus indicating that RMT is beneficial for the improvement of voice quality in stroke patients showing dysarthria. Further, considering that FEV1/FVC% was negatively correlated with Jitt, RAP, PPQ, and VTI, FEV1/FVC% may be correlated to voice quality, although no significant between-group difference after RMT was obtained for this parameter.

No adverse event was reported throughout the program, except in one subject with transient facial muscle soreness, which subsided within 2 to 3 days. Similar to previous studies, [10,11,33] the results proved that RMT could be feasible as adjunct therapy in stroke patients with respiratory muscle weakness, dysphagia, and dysarthria. However, the 6-week combined RMT was considered not long enough to demonstrate efficacy for expiratory muscle strength, swallowing, functional activity, and dysarthria and designing an intervention strategy based on the intensity, frequency, and duration of training program remains a challenge.

Study limitations: This study is limited by the small number of patients recruited. It took us two to three years to recruit the participants and those with apraxia, aphasia, and loose teeth, and those who could not hold a breath or perform a spirometry test were excluded. This study is also limited by the marked degree of drop-out rate (33.3% in RMT and 31.3% in control group). Moreover, the long-term effects and maintenance of RMT were not evaluated.

5 Conclusions:

Altogether, RMT significantly improved the respiratory muscle strength, FVC, FEV1, and fatigue in stroke patients with respiratory muscle weakness. In addition, the improvement in post-stroke dysphagia and dysarthria was also enhanced through RMT. The 6-week combined inspiratory and expiratory RMT is thus feasible as adjuvant therapy in stroke patients.

Acknowledgments

The authors would like to thank Andrew Wei-Hsiang Tiong for his assistance with this research.

Author contributions

Conceptualization: Mei-Yun Liaw, Chau-Peng Leong, Ching-Yi Liao, Cheng-Hsien Lu, Meng-Chih Lin.

Data curation: Mei-Yun Liaw, Chia-Hao Hsu, Chau-Peng Leong, Ching-Yi Liao, Lin-Yi Wang, Cheng-Hsien Lu, Meng-Chih Lin.

Formal analysis: Mei-Yun Liaw, Chia-Hao Hsu, Meng-Chih Lin.

Funding acquisition: Mei-Yun Liaw.

Investigation: Mei-Yun Liaw.

Methodology: Mei-Yun Liaw, Chau-Peng Leong, Ching-Yi Liao, Cheng-Hsien Lu, Meng-Chih Lin.

Resources: Chia-Hao Hsu, Lin-Yi Wang.

Supervision: Lin-Yi Wang.

Writing – original draft: Mei-Yun Liaw, Meng-Chih Lin.

Writing – review & editing: Mei-Yun Liaw.

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stroke; dysphagia; respiratory muscular training; acoustic analysis; functional performance

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• » News & Events
• » Integrating Patient-Reported Outcome Measures (PROMs) into Clinical Practice

Integrating Patient-Reported Outcome Measures (PROMs) into Clinical Practice

Background:

Assessing patient-reported outcome measures (PROMs) has become more prevalent throughout the healthcare field. By collecting PROMs, physicians gain insight into each patient’s care experience and view of his or her own health status.

This quantitative data has been shown to benefit clinicians, researchers, and patients alike. Randomized controlled trials have shown that PROM use improves patients’ quality of life and emotional well-being. PROMs have also been associated with enhanced patient-provider communication, streamlined monitoring of adverse events, and initiation of quality improvement measures.

How, when, and where PROMs should be incorporated into medical practice, will vary by clinician and/or institution. The following article highlights four real-world clinical scenarios and successful data collection techniques, providing physicians with options to consider when developing their own nascent PROM collection programs.

Validated Instruments and Data Capture Overview:

PROMs are typically quantified using instruments that have demonstrated consistency, reliability, validity, and responsiveness to change. Often, a patient-completed paper or electronic questionnaire is used to generate a summary score that represents a specific aspect of patient health status (e.g. nasal quality of life) and provide a scientific means to evaluate a patient’s condition

In each scenario below, otolaryngology practices outline their rationales for choosing a PROM method, describe their data collection processes and applications, and identify key elements of success.

Scenario 1: Pre- and Post-Intervention PROM Assessment via Paper Forms

One private practice group collects PROM assessments from patients receiving four common treatments: hearing aids, immunotherapy, nasal/sinus surgery, and pressure equalization tubes. Patients complete both a pre-intervention paper questionnaire and a follow-up phone survey post-intervention (six months to one year later). Validated tools used are the Hearing Healthcare Questionnaire, Rhinoconjunctivitis Quality of Life Questionnaire, Sinonasal Outcome Test (SNOT-22) and OtitisMedia-6 instrument.

Follow-up phone calls by a designated office staff member led to the highest rate of data completion. This PROM assessment sparked a performance improvement initiative and staffing change that resulted in significantly improved group outcome scores within the audiology department and was deemed to add value to the organization as a whole.

Scenario 2: PROM Assessment at All Outpatient Visits via Paper Forms Imported into the Electronic Medical Record

An academic laryngology practice collects the Voice Handicap Index-10 and the Reflux Symptom Index from all patients at every visit. The clinicians employ PROMs both for patient-care-related and research purposes.

Medical assistants manually input data from the paper forms into the EMR, and paper forms are also scanned into the EMR for future reference. Response rate is extremely high, as patients are not seen by a clinician until their surveys are completed. Notably, accurate and timely form completion may be a challenge for non-English-speaking patients needing interpreter assistance for each PROM assessment.

Scenario 3: PROMs Collected on Paper Collected at All Visits with Electronic Database Capture

One academic group rhinology practice uses PROM assessments both for research purposes and to trend patient outcomes. The SNOT-22 is a validated symptom survey that is administered to all patients with chronic rhinosinusitis at every visit. Medical assistants manually input data into EMR flowsheets so that symptom severity can easily be tracked over time. Data for research are subsequently entered into REDCap, a HIPAA-compliant electronic data capture platform.

As in the previous scenario, response rates are high, as patients complete their forms prior to their appointments. The clinicians anticipate improved patient outcome assessment with the addition of tablet-based input methods and the incorporation of data into quality metric reports.

Scenario 4: Electronic Database and EMR System Capture in Clinic and via Email

A facial plastic surgeon in a tertiary practice uses the NOSE survey to create individualized treatment algorithms for patients with nasal obstruction. PROMs are obtained strictly via tablets and follow-up emails, and all data is entered directly into the REDCap database by the surgeon. In this model, a designated computer programmer and clinical research coordinator are pivotal to the maintenance of the integrated EMR-REDCap system.

Response rates have been approximately 85% for this model. One obstacle to use is the burden to the physician who must input data on every patient.

Discussion:

PROMs have been integrated into clinical, academic, and research-oriented medical facilities. Paper forms are still common, though EMRs can now be used to seamlessly integrate a patient’s self-reported data into his or her clinical record. The development of a standardized PROM assessment is an important area of research potential. Eventually, a shared data set accessible to a vast network of providers and institutions could enhance both patient care and research efforts.

Conclusion:

The implementation of PROMs throughout the medical field is advantageous for patients and clinicians alike. Though data collection processes vary widely, PROMs have the collective potential to revolutionize healthcare delivery by promoting a patient-centered model of practice.

Carroll, TL; Lee, SE; Lindsay, R; Locandro, D; Randolph, GW; Shin, JJ. “Evidence-Based Medicine in Otolaryngology, Part 6: Patient-Reported Outcomes in Clinical Practice.” Otolaryngology – Head and Neck Surgery 2018; 158(1): 8-15. Accessed September 12, 2018.

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