FREQUENCY AND COOCCURRENCE OF

VOCAL TRACT DYSFUNCTIONS IN THE SPEECH

OF A LARGE SAMPLE OF PARKINSON PATIENTS

Jeri A. Logemann
Northwestern University Medical School, Chicago, Illinois

Hilda B. Fisher
Northwestern University, Evanston., Illinois

Benjamin Boshes and E. Richard Blonsky

Northwestern University Medical School, Chicago, Illinois

In this study, the frequency of occurrence of speech and voice symptoms in 200
Parkinson patients was defined by two expert listeners from high-fidelity tape re-
cordings of conversational speech samples and readings of the sentence version of
the Fisher-Logemann Test o] Articulation Competence. Specific phonemes that
were misarticulated were catalogued. Other vocal-tract dysfunctions, including laryn-
geal disorders, rate disorders, and hypernasality, were also recorded. Cooccurrence
of symptoms in each patient was tabulated. Examination of the patterns of co-
occurring dysfunctions permitted classifying the 200 patients into five groups: Group
1 (45% of file patients) with laryngeal dysfunction as their only vocal-tract symp-
tom; Group 2 (13.5% of the patients) with laryngeal and back-tongue involvement;
Group 3 (17% of the patients) with laryngeal, hack-tongue, and tongue-blade dys-
function; Group 4 (5.5% of the patients) with laryngeal dysfunction, back-tongue
involvement, tongue-blade dysfunction, and labial misarticulations; and Group 5
(9% of the patients) with laryngeal dysfunction and misarticulations of the back
tongue, tongue blade, lips, and tongue tip. Disfluencies and hypernasality did not
follow a systematic pattern of cooccurrence with other vocal-tract dysfunctions.

Most studies of c o m m u n i c a t i v e disorders in P a r k i n s o n patients have yielded

general impressions of the speech symptoms, such as "slurred, thick, indis-
tinct" (Kaplan, Machover, a n d R a b i n e r , 1954; Grewel, 1957; B i r k m a y e r a n d
Hornykiewicz, 1961; Chiasserini a n d C h i a p p e t t a , 1964; Allan, T u r n e r , a n d
Gadea-Ciria, 1966; Z i m m e r m a n a n d Canfield, 1966; Fasano, 1968; Sarno, 1968;
S a m r a et al., 1969; R i g r o d s k y a n d Morrison, 1970). Such descriptive terms have
b e e n a p p r o p r i a t e l y criticized by Darley, Aronson, a n d B r o w n (1969b) as in-
exact, since they f u r n i s h no basis for q u a n t i f y i n g the effects or m e a s u r i n g the

47

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 48 JOURNAL OF SPEECH AND HEARING DISORDERS XLIII 47-57 February, 1978

progress of the disintegration. Terms introduced by Darley et al. (1969a, b),

for example, "imprecise consonants," "phonemes prolonged," irregular artic-
ulatory breakdown," and vowels distorted," specify the symptoms but do not
delineate physiologic details of vocal-tract dysfunction. In addition, the de-
scriptions of Parkinson speech symptoms have implied that speech symptoms
were uniform among patients, and variability in speech symptoms was random
rather than systematic.
For years neurologists have employed a system of staging the symptoms of
Parkinson's disease to represent the degree of breakdown of general neuro-
muscular control and increase in tremor and rigidity (Yahr et al., 1968). Yet
no comparable staging of voice and articulation symptomatology has been
attempted. This is caused, in part, by the lack of epidemiologic information
on frequency of occurrence oE specific voice and articulation dysfunctions in
these patients. Collection of such data would have been hampered, in any
event, by the relatively small patient populations used in previous studies.
The availability of large numbers of Parkinson patients, at various stages
of the disease, in the Parkinson Clinic of the Northwestern University Medi-
cal Center, Chicago, provided us with the opportunity of initiating research
aimed at disclosing, if it existed, a sequence of degeneration in vocal-tract
control in Parkinson patients.
A long-term research project was initiated by the Northwestern University
Department of Neurology and the Voice Research Laboratory in the Depart-
ment of Otolaryngology. This study examines vocal-tract control in Parkinson
patients to understand the neuropathology and to evaluate and develop im-
proved therapy techniques better. This report presents the outcome of the first
group of studies that were designed to answer the following questions:

1. What is the frequency of specific vocal tract dysfunctions in a large sample of pa-
tients with Parkinsonism?
2. What are the specific phonemes affected by the reduction in lingual or labial
control?
3. What are the patterns of cooccurrence of various vocal tract dysfunctions in these
patients?

PROCEDURES

Two hundred Parkinsonian patients from the Parkinson Clinic of the

Northwestern University Medical School and from the private practice of staff
neurologists at the Northwestern-McGaw Medical Center, served as subjects
for the study. These patients represented all five stages of the disease-illus-
trating both the ideopathic and postencephalitic etiologies. Staging was de-
termined according to the Columbia system (Yahr et al., 1968) after complete
neurologic examination by a staff neurologist. At the time of testing, patients
were not receiving any anti-Parkinson medication. Either they had been with-
drawn from these medications for two weeks or they were newly diagnosed
patients not yet on medication.

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 LOGEMANN ET AL.: Vocal Tract Dysfunctions 49

Speech testing was completed in a sound-treated room (IAC model 400SP).

Each patient was required to read the sentence version of the Fisher-Loge-
mann Test o/ Articulation Competence (1971), which tests the consonant
phonemes of English in all syllabic positions (prevocalic, intervocalic, and
postvocalic). This reading, plus a 3- to 5-rain sample of conversational speech,
was recorded by means of an Electro-Voice Model 664 microphone coupled to
an Ampex Model AG350 tape recorder. A constant mouth-to-microphone dis-
tance of 8 in. was maintained.
A listening tape including a 2-rain sample from each patient's con-
versational speech, with 1-min of silence between each two samples, was pre-
pared. Twenty samples were repeated for reliability measures, making a total
of 220 taped samples. T w o trained listeners judged the tapes for specific rate,
voice, resonance, and articulation disorders. T o evaluate the speech samples,
each listener was seated in an IAC Model 400SP sound-treated room. T h e
listening tape was played on an Ampex Model AG350 tape recorder through
an Ampex Model 622 speaker-amplifier situated 180cm (six feet) in front of the
listener, at a comfortable loudness level. A remote control switch for the tape
recorder permitted the listeners to stop and replay any segment of the tape.
For every speech sample on the tape, each listener completed a data sheet
containing a list of the characteristics to be identified (see Appendix). Lis-
teners were instructed to note only the presence of a particular dysfunction
and specifically were asked not to rate the severity of the disorder: Laryngeal
disorders included the vocal quality aberrations of breathiness, roughness,
hoarseness, tremulousness, reduced pitch range, and a modal speaking pitch
inappropriate to the patient's age and sex. Rate disorders included repetition
of syllables, abnormally prolonged syllables, too-short syllables, and too-long
pauses. Hypernasality in any degree was the single resonance disorder identi-
fied. A check in the articulation category indicated that the patient had some
type of articulation defect. In this first listening session, judges were instructed
not to identify the phonemes in error but simply to note the presence of any
articulatory problems. Listeners were permitted as many replays of a taped
sample as necessary to determine whether each of the disorders listed was
present. Intrajudge agreement on this listening task was 0.97 and 0.95 for the
two judges. Interjudge agreement was 0.95.
T o determine the specific phonemes misarticulated by these Parkinson pa-
tients, a second listening tape was prepared, made up of each patient's record-
ing of 11 sentences from the Fisher-Logemann Test of Articulation Compe-
tence (1971). T h e same two trained listener-judges performed this task, under
the same listening conditions as for the first listening task. On a printed copy
of the test sentences (Figure 1), they were asked to circle the phonemes mis-
articulated by each patient. Only the first 11 sentences, which test consonant

lIn addition to these specific disorders, an unlabeled category within each subgroup per-
mitted judges to list any other dysfunction they identified.

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 50 JOURNAL OF SPEECH AND HEARING DISORDERS XLlll 47-57 February, 1978

9-62393
THE FISHER-LOGEMANN TEST OF ARTICULATION COMPETENCE

SENTENCE ARTICULATION TEST

/p /b /p /b /b /1",
/p, b/ 1. Pete's j o b was to keep the ba by hap._.ppy.

It /d /d It /d /t /t
/t, d/ 2. To day Dick tol d Patty about it.

| | @0r
/k, g/ 3. The g_iris were baking the biggest ca ke for Mr. Tag.

1~ /~ /~ /0 /0 /0
/o, ~1 4. Th.__..eirbrother wouldn't bathe because he th.__oughta bath would make his tooth..ache worse.
/t l{ /v /v /t /v /v
/f, vl 5. In a half day, he repaired fi ve television sets, two telephones, and a very old stove.

/s, z~ 6. Su zie sewed zippers on two new dresses at Bess ie's house.

/L s/
O@ 9 0 O
7. She usually rushes to push the garage door closed.

00 9 | 0
/tL as/ 8. George is at the church watching a magic show.

/w /r /l /r /t / w /t /r
/ r , 1, w / 9. t,Ve r_ode with Lucy around the tall tower in her new yellow car.

1~, /h I~, /h lh /J /h /J
/~,,j,h/ 10. Why haven't you looked anywh__ere behind the house or be .yond the hill yet?

/n /n /m /n /r) /m /tj /m /n
/m,n,~/ 11. N a n c y found some fine hangers am ong the m any things at the sale.

Figure 1. Representative completed record form of the Sentence Test, showing misarticulated consonant
phonemes circled.

phonemes, were analyzed. For this study, they were instructed not to note the
type of error produced by the patient but simply to identify each phoneme
misarticulated. Again, 20 samples were repeated for reliability measures. Intra-
judge agreement for this relatively simple listening test was 100% for both
judges, and interjudge agreement was also 100%.

RESULTS

Frequency of Vocal Tract Disorders. Table 1 presents a profile of vocal-

tract disturbances according to relative frequency of occurrence in the popula-
tion of 200 Parkinson patients studied. Voice (laryngeal) disorders, comprising
breathiness, hoarseness, roughness, and tremulousness, were the most frequent
abnormalities, occurring in 89% of the patients. Next in frequency were articu-
lation disorders (lingual, labial, or both), which occurred in 45% of the pa-

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 LOGEMANN ET AL.: Vocal Tract Dysfunctions 51

TABLE 1. Percent of occurrence of vocal tract disorders in the

200 Parkinson patients, as identified by two trained listeners.

Number oI % ol
Vocal Tract Disorder Patients Patients
Laryngeal disorders 178 89
Breathiness 30 15
Roughness 58 29
Hoarseness 90 45
Tremulousness 27 13.5
Other 0 0
Articulation disorder 90 45
Rate disorders 40 20
Repetition of syllables 31 15.5
Abnormally long syllables 12 6
Too-short syllables 21 10.5
Too-long pauses 4 2
Other 0 0
Hypernasality 20 10
No vocal tract disorder 22 11

tients. Disorders of speech rate appeared in 20%. Least frequent were distur-
bances of resonance (hypernasality), that occurred in only 10% of the patients.
U n i m p a i r e d vocal-tract control was seen in 11% of the Parkinson patients
studied. These figures reveal that the typical Parkinson patient is highly likely
to have a voice quality disorder and an approximately even chance of having
an articulation disturbance. But he is less likely to have problems with either
speech rate or resonance (a disorder of velar valving).
Specific P h o n e m e s Misarticulated. A record of each patient's consonant
misarticulations was prepared by each of the listener-judges. Neither the pre-
cise nature of each error nor the n u m b e r of errors per phoneme by a single
subject was specified. It was observed, however, that a misarticulated conso-
n a n t phoneme tended to be misarticulated with high consistency in this task.
Next, the n u m b e r of subjects misarticulating each phoneme was tallied,
and the frequency of errors for each phoneme in the total subject population
was entered on a descriptive feature matrix (Figure 2). A survey of the distri-
b u t i o n of errors on this feature matrix permits several immediate observations.
First, errors are highly concentrated in the obstruent consonants--stops,
fricatives, and affricates. T h e dysarthria most affects those consonant pho-
nemes requiring greatest constriction of the vocal tract in their production.
Second, an examination of cognate pairs, for instance, / p / - / b / or / f / - / v / ,
shows no difference in frequency of errors between the voiced and the voice-
less cognates.
Figure 2 shows that the deterioration in consonant production in these pa-
tients does not involve the voicing feature, b u t the m a n n e r and place features.
Such a simple count of error frequencies for the various phonemes discloses
the phoneme classes most affected by Parkinson's disease; yet these figures fail

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 52 JOURNAL OF SPEECH AND HEARING DISORDERS XLIII 47-57 February, 1978

M a n n e r of F o r m a t i o n
Place
of i_~ Stop Fricative Affricate Glide Lateral .'\'asa [

Articulation >- c
m

,~ .29 /~/:0
Bilabial ~ - - ~ ~
v i.
/bl :29,
.;_ . .
lwl'O /m/:6

Labio-dental J--'----~--
\: /v/'27
u /0/'16
Tip-dental -' ~ ~ 9
i\: /~/.16

Tip-alveolar
u I t / " -18
-
v / d / . 18 /(/:6; In/'6
Blade- ~ l /s/- 63
alveolar V "63

Blade- ~ _ _ _ _ _ ~ / . . . . ~4. _3~ / //" t ( " 3_~_gg

l--1 /.j/~0

I palatal IV ! - - : ' ] i /:r/-6 [ ; ,

Back-ve|ar . . . . ' ' ' ' '

v Igl.9O J In/'0
O,ott~, + 1 Ifd:o " " 1i
Figure 2. Number of patients misarticulating each phoneme, displayed on descriptive feature matrix.

to reveal the cooccurrence of symptoms in individual patients or groups of

patients.
Cooccurrence o[ Dys[unction in Lingual and Labial Control. In an attempt
to disclose the cooccurrence of errors in articulation, the 200 patients were
rank-ordered from those having fewest error phonemes to those having the
most. This list included a catalog of each person's error phonemes as well as
the total number of his misarticulated phonemes.
A pattern of cooccurrence of articulation errors was sought by plotting the
error phonemes according to their manner features. No clear pattern of error
clustering could be observed in terms of manner features.

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 LOGEMANN ET AL.: Vocal Tract Dysfunctions 53

9~ ~

8~

~o ~1~

c~

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 54 JOURNAL OF SPEECH AND HEARING DISORDERS XLIII 47-57 February, 1978

Data from the 200 patients then were replotted according to place features.
Table 2 shows data for a representative portion of the population studied (25
of the 200 patients). This plotting of the data according to place features
makes the clustering of articulation errors apparent. Note that those patients
having fewest error phonemes show errors on the / k / and /g/ phonemes.
These two back-velar stops were the only two phonemes solely affected, and
every patient with an articulatory disorder misarticulated / k / and /g/. The
alveolar fricatives /s/ and /z/ followed the / k / and /g/ in error frequency.
Next were the cognate prepalatal fricatives /J'/ and /5/, followed by the pre-
palatal affricates ~tf~ and /d3/. T h e labial phonemes, including the bi-
labial stops / p / and /b/ and the labiodental fricatives /f/ and /v/, were
affected less frequently than /t.f/ and /d3/. The least frequently misarticu-
lated phonemes were the tip-alveolar s t o p s / t / a n d / d / .
Classification of patients into four groups emerged from this analysis, based
on the pattern of cooccurrence of articulatory problems shown in Table 2.
First, only the back-tongue phonemes /k/ a n d / 9 / were misarticulated solely.
Thus, Group 1 includes 13.5% of the patients studied, who showed only this
back-tongue involvement and otherwise normal articulation. Group 2 includes
patients with tongue-blade dysfunction /s, z, f, 3, t f, ds/ as well as back-
tongue dysfunction. Seventeen percent of the patients showed involvement of
the tongue blade and back tongue, with all other articulations normal. T h e
third patient group defined includes those who displayed back tongue, blade
of tongue, and labial dysfunction. Five-and-one-half percent of the patients
showed dysfunction in these three areas of the vocal tract. The fourth group
of patients included those who misarticulated back tongue, tongue blade,
labial, and tongue-tip phonemes. Nine percent of the patients displayed this
cooccurrence of articulation symptoms.
Cooccurrence of Laryngeal Dys[unction with Articulatory Dys[unction. All
of the patients with articulation disorders were listed in order from fewest to
largest number of error phonemes, as illustrated in Table 2. For each patient
on this listing, notation was also made of any laryngeal dysfunction, reso-
nance disorder, or rate anomaly. Patients having one of these additional dis-
orders but no articulation dysfunctions were listed also. This listing revealed
a clear pattern of cooccurrence between laryngeal and articulatory dysfunc-
tions.
Of the total patient population, 89% demonstrated laryngeal dysfunction.
Further, 45% of the patients showed laryngeal dysfunction as the sole symp-
tom, with no articulation errors demonstrated. Every patient (except one 2)
who demonstrated any articulation problems also showed laryngeal dysfunc-
tion.

2This patient had undergone thalamic surgery approximately six years prior to this ex-
amination and therefore may not be typical of the Parkinson population. However, he may
also belong to a subgroup of Parkinson patients not represented in this study.

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 LOGEMANN ET AL.: Vocal Tract Dysfunctions 55

Using this information on the cooccurrence of laryngeal and articulatory

dysfunctions, the four patient groups previously defined must be expanded to
the five patient groups shown in Table 3. Forty-five percent of the patients
were included in Group 1 with laryngeal dysfunction (hoarseness, roughness,
or tremulousness) as their only vocal-tract symptom. Thirteen-and-one-half

"FABLE 3. Percent of cooccurrence of vocal tract dysfunctions in the

200 Parkinson patients.

Percentage o]
Cooccurrence o] Vocal Tract Symptoms Patients
Laryngeal dysfunction 45
Posterior lingual dysfunction plus the above 13.5
Tongue blade dysfunction plus all the above 17
Labial dysfunction plus all the above 5.5
Tongue-tip dysfunction plus all the above 9

percent of patients were included in Group 2 with back-tongue /k/ and /9/
involvement in addition to laryngeal dysfunction, comprising hoarseness,
roughness, breathiness, and tremulousness. Group 3 included 17% of the pa-
tients. These individuals showed laryngeal, back tongue, and tongue-blade
dysfunction /s, z, f, 5, tf, ds/. Hoarseness was the only laryngeal symptom
noted in these patients. Patients in Group 4, including 5.5% of the population
studied showed laryngeal dysfunction (hoarseness), back-tongue involvement,
tongue-blade dysfunction, and labial misarticulations /p, b, f, v[. Group 5,
9% of the patients, included laryngeal dysfunction (hoarseness), and misartic-
ulations of the back tongue, tongue blade, lips, and tongue tip /t, d].
Cooccu~ence of Rate Disorders and Hypernasality with Articulatory and
Laryngeal Dysfunction. Rate disorders (20%) and hypernasality (10%) were
the least frequent speech symptoms in this population. Occurrence of these
symptoms followed no regular pattern of cooccurrence with the lingual, labial,
or laryngeal articulatory dysfunctions. Projected research in acoustic and
physiologic features of rate abnormalities in Parkinson patients may further
clarify possible relationships between the disfluency and articulatory dysfunc-
tions. The nature of Parkinson disfluencies and their possible cooccurrence
with other neurologic symptoms in the same patient, particularly gait and
tremor patterns, will be examined.

DISCUSSION

These results have several implications. First, the patterns of coexistence of

various vocal-tract dysfunctions may indicate natural subgroups of Parkinson
patients. Thus, each patient subgroup represents a specific pattern of neuro-
logic lesions that cause the particular cluster of vocal-tract problems. For
example, patients with a combination of laryngeal dysfunction (hoarseness)

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 56 JOURNAL OF SPEECH AND HEARING DISORDERS XLIII 47-57 February, 1978

and reduction in lingual control may have lesions affecting control of Cranial
Nerves 11 and 12, while patients with only laryngeal dysfunction may have
neurologic lesion(s) involving control of C11 alone.
T h e fact that none of the 200 patients included in this study showed labial
dysfunction or lingual dysfunction as their sole vocal-tract disorder indicates
only that no such patients were included in this sample. It does not neces-
sarily indicate that such problems or patterns of problems do not exist in
Parkinson patients. Other Parkinson patients may show these dysfunctions as
their only vocal tract symptom.
Another interpretation of the data may be that these clusters of symptoms
represent a progression in dysfunction, beginning with laryngeal changes and
increasing to include other areas of neuromuscular control of the vocal tract,
for example, lips and tongue. Looking at the data in this way suggests that
deterioration in speech and voice in Parkinson patients begins with laryngeal
symptoms of breathiness or roughness, followed by disability in control of the
back of the tongue, and proceeding to anterior lingual place of articulation.
Labial articulations are affected some time after lingual control has started to
degenerate. This hypothesis of predictable progression of dysfunction remains
to be tested in a longitudinal study of a large group of Parkinsonian patients.
Changes in each patient's vocal-tract control over time could then be assessed
and any progressive degeneration corroborated.

ACKNOWLEDGMENT

This research was supported by the Sterling-Morton Charitable Trust to Northwestern

University Medical School, Department of Neurology. Hilda Fisher is also at Northwestern
University Medical School, Chicago, Illinois. Requests for reprints should be directed to Jeri A.
Logemann, Department of Neurology, Northwestern University Medical School, 303 East Chi-
cago Avenue, Chicago, Illinois 60611.

REFERENCES

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RICRODSKY, S., and MORRISON, E., Speech changes in Parkinsonism during L-Dopa therapy:
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Received September 7, 1976.

Accepted March 11, 1977.

APPENDIX

List of disorders for use by trained listeners in identifying vocal tract dysfunctions in
Parkinson patients.
Vocal Tract Disorders
if present
Laryngeal Disorders
Breathiness
Roughness
Hoarseness
Tremulousness
Reduced Pitch Range
Inappropriate Modal Speaking Pitch
Other
Rate Disorders
Repetition of Syllables
Abnormally Prolonged Syllables
Too-Short Syllables
Too-Long Pauses
Other
Hypernasality
Articulation Disorder
Other

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