Application of the ICF in Reduced Speech

Intelligibility in Dysarthria
Allyson D. Dykstra, Ph.D.,1 Mark E. Hakel, Ph.D.,2 and Scott G. Adams, Ph.D.3

ABSTRACT

Regardless of the underlying neuromotor impairment, an almost

universal consequence of dysarthria is a reduction in speech intelligibility.
The purpose of this article is to examine critically and to discuss issues
related directly to speech intelligibility in speakers with dysarthria. Reduced
speech intelligibility resulting from dysarthria is examined using the World
Health Organization’s International Classification of Functioning, Disabil-
ity and Health (ICF) conceptual framework. We propose that the ICF
conceptual framework facilitates an awareness of the multidimensional
nature of disablement. Furthermore, the ICF facilitates a broad under-
standing of the complex nature of dysarthria, ranging from the neuro-
anatomical and physiological substrates contributing to reduced speech
intelligibility, to the effects of this type of communication disorder on an
individual’s functioning in society and beyond. Finally, a case example is
presented that describes how the ICF can be applied to an individual with
dysarthria and reduced speech intelligibility.

KEYWORDS: Dysarthria, motor speech disorders, speech intelligibility,

ICF

Learning Outcomes: As a result of this activity, the reader will be able to describe the complex and
multidimensional nature of the disablement process associated with reduced speech intelligibility in dysarthria
using the World Health Organization’s ICF conceptual framework.

1
Research Associate, School of Communication Sciences
and Disorders, University of Western Ontario, London,
Ontario, Canada; 2Director, Education and Staff Develop-
ment, Institute for Rehabilitation Science & Engineering,
Madonna Rehabilitation Hospital, Lincoln, Nebraska;
3
Associate Professor, School of Communication Sciences
and Disorders, University of Western Ontario London,
Ontario, Canada.
Address for correspondence and reprint requests:
Allyson Dykstra, Ph.D., Research Associate, School
of Communication Sciences and Disorders, Elborn
College, University of Western Ontario, London, Ontario,
N6G 1H1 Canada (e-mail: apage2@uwo.ca).
The International Classification of Functioning,
Disability and Health (ICF) in Clinical Practice; Guest
Editors, Estella P.-M. Ma, Ph.D., Linda Worrall, Ph.D.,
and Travis T. Threats, Ph.D.
Semin Speech Lang 2007;28:301–311. Copyright #
2007 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584–
4662.
DOI 10.1055/s-2007-986527. ISSN 0734-0478.
301
302 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
T he modern definition and characteriza-
tion of dysarthria is based extensively on the
prominent work of Darley et al.1–3 These re-
searchers defined dysarthria as ‘‘a collective
name for a group of speech disorders resulting
from disturbances in muscular control over the
speech mechanism due to damage of the central
or peripheral nervous system’’ (p. 246).2 The
definition ‘‘designates problems in oral commu-
nication due to paralysis, weakness, or in coor-
dination of the speech musculature’’ (p. 246).2
Dysarthria often is associated with chronic
neurodegenerative diseases such as amyotrophic
lateral sclerosis (ALS) that results in mixed
dysarthria, Parkinson’s disease (PD) that leads
to hypokinetic dysarthria, or Friedreich’s ataxia
that results in ataxic dysarthria. Regardless of
the underlying neuromotor impairment, an al-
most universal consequence of dysarthria is a
reduction in speech intelligibility. Attempting
to improve or increase speech intelligibility
often is a primary intervention goal not only
in the context of behavioral speech therapy but
often is a desired end point for speakers with
dysarthria.
Speech intelligibility is described as ‘‘the
behavioural standard of communication’’
(p. 1).4 It is defined by Yorkston et al5 as
the ‘‘degree to which the acoustic signal is
understood by the listener’’ (p. 55). More
broadly, speech intelligibility can be viewed
as the ‘‘understandability of speech.’’4,6 Speech
intelligibility supports effective and efficient
spoken language and is one of the foremost
issues of importance in speech-language path-
ology. Yorkston et al7 described the measure-
ment of speech intelligibility as the ‘‘primary
measure of disability’’ in speakers with
dysarthria.
The purpose of this article is to examine
critically and to discuss issues related directly to
speech intelligibility in speakers with dysarthria
from a perspective that synthesizes several as-
pects of an individual’s functioning. We pro-
pose that for researchers and clinicians to
understand and to treat the reductions in
speech intelligibility resulting from dysarthria,
they need to transcend traditional estimates of
severity and instead must include information
related to the anatomical and physiological
underpinnings of reduced speech intelligibility
2007
as well as the societal impact of reduced intelli-
gibility on the individual.
DYSARTHRIA AND BODY
FUNCTIONS AND STRUCTURES
The dysarthrias represent a diverse group of
motor speech disorders and have been classified
in numerous ways to include site of lesion (i.e.,
cortex, basal ganglia, cerebellum), age of onset
(i.e., congenital versus acquired), neurologic di-
agnosis (i.e., vascular, degenerative, inflamma-
tory), or course (i.e., congenital, improving,
degenerative). The most widely accepted classi-
fication and gold standard is based on the
Mayo Clinic rating and classification system
(Darley et al).1–3 This system uses an auditory–
perceptual classification to describe the dysarth-
rias. Six types of dysarthria (flaccid, spastic,
ataxic, hypokinetic, hyperkinetic, and mixed)
are identified based on clusters of salient percep-
tual features associated with lesions in the central
and peripheral nervous systems unique to each
dysarthria type. Darley et al categorized speech
and voice features based on respiration (b440);
resonance, voice, pitch, loudness (b310); prosody
(b330); and articulation (b320), as well as the
two general parameters of intelligibility and
bizarreness. The most distinctive and salient
perceptual speech characteristics were deter-
mined and an auditory–perceptual profile
was constructed for each of the six categories of
dysarthria. This article uses the auditory–per-
ceptual scheme presented by Darley et al1–3
because this classification system is most widely
used by researchers and clinicians and has helped
guide several hypothesis-driven studies about
the physiologic substrates of the dysarthrias.8
The reduction in speech intelligibility
associated with the dysarthrias represents a com-
plex interaction of physiological (Body Func-
tions component) and anatomical (Body
Structures component) changes to the speech
production mechanism (see Duffy8 for a thor-
ough review). There are numerous physiological
studies in the dysarthria literature in which
researchers investigated the speech motor defi-
cits associated with specific neurological diseases
such as PD, ALS, dystonia, chorea, and pseudo-
bulbar palsy.9 Physiological studies also have
helped to reveal pathological phenomena that

challenge current hypotheses and models of
normal speech production9 and have greatly
increased our knowledge of the pathophysiolog-
ical underpinnings of the dysarthrias. With a few
notable exceptions, there are few studies in the
literature that have investigated the physiolog-
ical correlates of speech intelligibility associated
with the dysarthrias. Speech intelligibility has
been studied in relation to orofacial force
dynamics,10,11 tongue function,12,13 and lower
lip displacement amplitude and velocity.14
Although the physiological study of dysarthria
has a well-established literature, the physiolog-
ical correlates of speech intelligibility have not
yet been ascertained, and the causal links to
speech intelligibility are still poorly understood.
There appears to be no clear cause–effect rela-
tionship between subsystem physiology and
speech intelligibility. Conceptualizing speech
intelligibility from a physiological perspective is
not a trivial task. Presumably, one reason why so
few studies of this nature exist could be due to
the complex nature of speech intelligibility.
Speech intelligibility is a construct based on a
unique combination of respiratory, laryngeal,
velopharyngeal, and articulatory–prosodic phys-
iological motor subsystems. Not only is there
considerable variation among dysarthria groups,
but there is considerable individual variation
within a specific dysarthric group. In addition
to the motor subsystem approach of conceptu-
alizing speech intelligibility, speech intelligibil-
ity also includes personal and environmental
contextual factors unique to the individual with
dysarthria and decreased speech intelligibility.
DYSARTHRIA AND ACTIVITY
This section focuses on examining speech in-
telligibility in speakers with dysarthria from an
Activity level of functioning. Activity refers to
the execution of a task or action by an individ-
ual.15 Activity limitations refer to the difficulties
experienced by an individual, in the context of a
health condition, that can impact performance
or execution of an activity.15 Using the World
Health Organization’s (WHO) International
Classification of Functioning, Disability and
Health (ICF) conceptual framework, speech
intelligibility often is most associated with the
Activity level of functioning (d330), but the
APPLICATION OF ICF TO DYSARTHRIA/DYKSTRA ET AL 303
components that can comprise intelligibility
(i.e., articulatory, velopharyngeal, laryngeal, res-
piratory and/or prosodic factors) all can be
linked with the construct of Body Functions
and Structures. By virtue of its conventional
definition [i.e., ‘‘the degree to which the acoustic
signal (utterance produced by the dysarthric
speaker) is understood by a listener’’5], speech
intelligibility refers to the execution or perform-
ance of a task by an individual.
During the assessment of speech intelligi-
bility, all communicative contexts are highly
controlled to measure the adequacy of the
speech signal in isolation from semantic and
syntactic factors. These factors are controlled
through the use of standardized words, senten-
ces, or reading passages. In addition, most
contextual factors are minimized by using lis-
teners who are unfamiliar with the material, as
well as using quiet testing environments. From
this standardized material, an index of severity
is generated based on the percentage of words
correctly understood and transcribed by a lis-
tener divided by the total number of words
produced by the speaker multiplied by 100.
Therefore, speech intelligibility typically is ex-
pressed as a percentage and is used routinely to
assign an index of severity to the speaker.
The term intelligibility often is preceded
by a descriptor that illustrates what type of
intelligibility is being measured. For example,
intelligibility tasks and activities can examine
phoneme intelligibility,16 single-word intelligi-
bility,17 and/or sentence intelligibility.16–19
Yorkston et al6 suggest that the distinction
made between intelligibility tasks is dependent
largely in the type of question being asked. For
example, sentence intelligibility tasks typically
are concerned with quantifying severity or level
of performance, whereas, phoneme intelligibil-
ity tasks typically are concerned with answering
questions regarding the nature of articulatory
error patterns.6 Speech intelligibility can be
evaluated and measured with a variety of tech-
niques, but it cannot be interpreted without
relating to how it was measured.
Phoneme Intelligibility
Measures of phoneme intelligibility typically
examine errors in singleton consonants, vowels,
304 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
and diphthongs. The Phoneme Intelligibility
Test developed by Yorkston et al20 requires
the speaker to read or imitate 57 words con-
taining target phonemes comprised of initial
consonants, final consonants, vowels, and diph-
thongs. An advantage of phoneme intelligibility
tasks is that specific phoneme error profiles can
be generated for a given speaker. Specific goals
for intervention can be chosen, and monitoring
of changes in intelligibility can be evaluated in a
systematic way using phoneme intelligibility
tasks.
Single-Word Intelligibility
There are numerous reasons for choosing
single-word intelligibility tasks. One practical
reason is that single-word tasks are not as
physically demanding or fatiguing as sentences
for individuals with severe dysarthria. When
using single-word tasks for measuring intelli-
gibility, it is important to examine the effects of
context and predictability of words. Tasks ex-
amining semantically predictable single words
can be chosen to replicate what can happen in a
natural communication setting in which listen-
ers often have some information regarding the
topic of conversation. In addition to the pre-
dictability of semantic context, speaker varia-
bles also are important. For example, Yorkston
and Beukelman21 suggested that single-word
intelligibility scores are higher than sentence
intelligibility scores in speakers with more
severe dysarthria and significantly reduced
intelligibility, whereas in more intelligible
speakers with dysarthria, scores typically are
higher for sentence intelligibility tasks than
for single-word tasks.
Sentence Intelligibility
Sentence intelligibility tasks frequently are
cited in the literature.16–19 One possible ex-
planation for the popularity of sentence intelli-
gibility tasks is that they provide a measure of
severity or deviation from a normative score/
population. The Sentence Intelligibility Test
(SIT)22 is the most widely used test of sentence
intelligibility for individuals with dysarthria.
A review of the literature on speech in-
telligibility in dysarthria reveals that indices of
2007
overall severity are the primary means of
measuring speech intelligibility. Strand and
Yorkston23 reported that 70% of the articles
they reviewed related to dysarthria over a 9-year
period used speech intelligibility as an index of
the severity of dysarthria. Yorkston et al7 in-
dicated that intelligibility scores (i.e., overall
severity) routinely are used because this type of
assessment information is easy for the individ-
ual with dysarthria to understand, a knowledge
of the physiology of the speech subsystems is
not required, and finally, individuals with dys-
arthria usually view their dysarthria from this
functional perspective.
Despite the popularity and relative advan-
tages of using speech intelligibility as an index
of severity for speakers with dysarthria, it also is
important to explore other aspects of the indi-
vidual’s functioning to ensure rehabilitation
success and to broaden our concept of speech
intelligibility. Kent et al24 maintain that it is
vital to interpret an intelligibility score relative
to the conditions under which the intelligibility
scores were obtained, and cites listener and
speaker variables, test materials, and test pro-
cedures as factors to consider when interpreting
an intelligibility score. It also is necessary to
examine speech intelligibility from a perspec-
tive that incorporates communicative perform-
ance in natural settings as well as an inclusion of
signal-independent information contributing
to the communicative failure or success of the
speaker with dysarthria. Therefore, it is impor-
tant to examine factors contributing to intelli-
gibility beyond the person’s capacity to execute
a task or an action (Activities level of function-
ing) and explore intelligibility from a perspec-
tive that examines the effect of reduced speech
intelligibility on one’s involvement in a life
situation (Participation level of functioning).
DYSARTHRIA AND PARTICIPATION
Participation refers to the nature and extent of
an individual’s involvement in life situations.15
Restrictions in Participation represent the dif-
ficulties individuals can experience in life sit-
uations due to the circumstances of their
health condition.15 According to the ICF
conceptual framework, Participation repre-
sents an individual’s participation in society

and society’s response to either facilitate or
hinder that participation. Within the realm of
communication, Participation refers to the
roles and activities that one chooses that in-
volve communication within the context of
everyday life.15
Comprehensibility/Operational
Intelligibility
The term comprehensibility was used by
Yorkston et al5 to refer to the ‘‘adequacy of
speech performance in a social context’’ (p. 57),
as well as the measurement of speech intelli-
gibility within a communicative context. Sim-
ilarly, Enderby25 used the term operational
intelligibility to refer to the concept that
speech intelligibility is the outcome of a com-
plex communication channel that is influenced
by physical, pragmatic, and linguistic variables.
Both comprehensibility and operational intel-
ligibility include speech intelligibility as their
main component, but they differ from the
traditional definition of speech intelligibility
because they incorporate all available contex-
tual cues or signal-independent information.
This includes any information available to the
listener that supplements the acoustic signal,
such as syntactic or semantic content, or use of
gestures, facial expressions, alphabet cues, cues
available from the physical environment, or
communication breakdown strategies.5,25,26
Comprehensibility and operational intelligi-
bility measures add an additional level of
complexity to traditional measures of speech
intelligibility. Comprehensibility and opera-
tional intelligibility facilitate the measurement
of intelligibility in a natural communicative
context and provide a better estimate of func-
tional communication than traditional decon-
textualized estimates of speech intelligibility.
Little is known of the societal issues that
restrict or limit the life participation of individ-
uals with reduced speech intelligibility resulting
from dysarthria. Understanding the Participa-
tion dimension of functioning in individuals
with reduced speech intelligibility is a difficult
task, but it is essential to speech-language path-
ologists because it can help guide research ques-
tions, clinical practice, and ultimately, facilitate
meaningful rehabilitation practices. Yorkston
APPLICATION OF ICF TO DYSARTHRIA/DYKSTRA ET AL 305
et al27 used a phenomenological approach to
examine communication in individuals with
multiple sclerosis. Specifically, this qualitative
research method was used to obtain an ‘‘insider’s
perspective’’ of the disablement experience
through the use of in-depth interviews. Of the
seven individuals studied, two presented with
mild dysarthria. These researchers found that
concerns about communication focused primar-
ily on issues surrounding life participation and
communicative competence in society. Sub-
themes that emerged from the interview process
revealed that participation was important; com-
municative participation had changed and was
limited by numerous factors such as speech and
language changes, cognitive-communication
changes, fatigue, and visual changes; communi-
cation problems were variable; and that individ-
uals with dysarthria felt that they were treated
differently by others27 (e410, e415, e420, e425,
e445, e460). One participant with reduced
speech intelligibility associated with ataxic dys-
arthria revealed that her speech difficulties lim-
ited her communicative participation. She
described discordance between what she was
thinking and how she sounded when speaking.
In addition, she reported that her speech fre-
quently was not understood by others.27
Another participant with mild dysarthria
revealed that the changes in her speech (pre-
sumably reduced speech intelligibility) signaled
that she was different, and, as a result, she was
treated differently by others27 (e410, e415, e420,
e425, e445, e460). One interesting finding that
emerged from this investigation was that even
mild speech impairments resulted in significant
restrictions in communicative opportunities,
and hence, participation. This study reveals
poignantly the importance of speech intelligi-
bility at a societal level. It also demonstrates that
restrictions in participation cannot necessarily
be predicted from the severity of the speech
intelligibility deficit. This study emphasizes how
the ICF conceptual framework can facilitate an
understanding of the complex and nonlinear
nature of the disablement process.
Other researchers also have described is-
sues surrounding participation in individuals
with acquired communication disorders.
Hirsch and Holland suggested that the social
milieu rather than the physical environment
306 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
yields the greatest impact on successful com-
munity participation for individuals with
acquired communication disorders.28 For in-
stance, these authors presented an example of
an individual with impaired communication
who could physically access a building to
attend a social function, but without the ap-
propriate communication support, had the
potential to be unable to participate socially
in the event.
The disability associated with reduced
speech intelligibility can influence an individu-
al’s social role. When examining speech intelli-
gibility from this perspective, both the social
milieu and the physical environment can con-
tribute to the Participation or Participation
restrictions by individuals with dysarthria.27
The social environment can take diverse forms
such as work, education, volunteering, as well as
the maintenance of friendships and interperso-
nal relationships. These environments can pro-
vide either communicative barriers or
facilitators to one’s social participation. Com-
municative barriers can include avoiding ini-
tiating conversations at work because of the
perceived (real or otherwise) negative reactions
by coworkers (e425, e430, e435), or losing
interpersonal relationships if friends become
uncomfortable around an individual with re-
duced speech intelligibility (e420, e425, e590).
Volunteer work often becomes an important
option to communicative participation if indi-
viduals feel that perfect speech is not re-
quired.27 Volunteer work can be perceived as
less threatening than traditional work environ-
ments and provides an opportunity for commu-
nicative participation (d855). In addition to the
social milieu, the physical environment such as
lighting (e240) and acoustics (e250) can play an
important role in communicative participation.
Barriers to participation can be minimized
through the use of environmental adjustments
such as adequate lighting and acoustic en-
hancers that facilitate optimal speaking and
listening environments (i.e., carpeting, drapery,
voice amplifiers). Therefore, participation in
life activities can interact with, or can be influ-
enced by, Environmental Factors such as the
physical environment (e240, e250), the social
environment, or the attitudinal environment
(e460) of the society in which one lives.
2007
Conceptualizing speech intelligibility from
the perspective of communicative participation
is difficult, but essential to both the compre-
hensive assessment of intelligibility and to the
development of relevant and contextually mean-
ingful treatment plans. The use of extensive and
lengthy interviewing techniques is not a clin-
ically viable solution to obtain participation-
related information. However, as Yorkston
et al27 suggest, using components of the inter-
view technique such as asking the right ques-
tions can help direct us to issues surrounding the
assessment and treatment of ‘‘communication in
context’’ for individuals with dysarthria. Fur-
thermore, these authors advocate for the con-
tinued development of appropriate outcome
measures such as the American Speech-Lan-
guage Hearing Association’s (ASHA) Func-
tional Assessments of Communication Skills
for Adults,29 the ASHA Quality of Communi-
cation Life Scale (QCL),30 and the Communi-
cation Effectiveness Index—Modified (CETI-
M)31 that capture communication participation
and social participation in adults with neuro-
genic communication disorders (see Eadie
et al32 for a thorough review).
Communicative participation in individu-
als with reduced speech intelligibility is linked
closely to the social, physical, and attitudinal
environments in which they live. For the pur-
pose of clarity in this article, the Participation
level of functioning has been separated from
contextual factors such as the Environment.
However, it is important to recognize that there
is a strong interrelationship between the Par-
ticipation and contextual levels of functioning
within the framework of the ICF. The follow-
ing section examines the contextual factors that
can influence an individual with dysarthria who
has reductions in speech intelligibility.
DYSARTHRIA AND CONTEXTUAL
FACTORS (ENVIRONMENTAL AND
PERSONAL FACTORS)
Contextual Factors in the ICF framework in-
clude both Environmental and Personal Fac-
tors. These factors can impact positively (i.e.,
facilitating) or negatively (i.e., hindering) on
the individual with a health condition by ex-
erting an influence on the individual’s body

functions or structures, the individual’s ability
to perform a task, or the individual’s perform-
ance as a member of society.15 According the
ICF conceptual framework, environmental fac-
tors include the physical, social, and attitudinal
environment in which people live and conduct
their lives. Furthermore, environmental factors
are subdivided into individual and societal lev-
els. In general, individual factors include the
immediate environment of the individual, in-
cluding the home or workplace environments,
as well as physical and material features of the
environment such as direct contact with others
(i.e., family, peers, strangers).15 Societal factors
include formal and informal social structures
and services that can influence the individual,
such as government agencies, attitudes, ideolo-
gies, and laws.15
Environmental Factors
There are few published studies on the effects
of Environmental Factors on reduced speech
intelligibility in dysarthria. Some notable ex-
ceptions are studies conducted by Garcia et al33
and Yorkston et al.34 Garcia et al33 described
the perceived barriers to work integration for
groups of individuals representing a variety of
communication disorders (i.e., aphasia, hearing
loss, voice disorders, post-laryngectomy speech,
persons who stutter, and dysarthria). It is un-
clear whether the individuals studied with
dysarthria presented with reduced speech in-
telligibility. However, common themes that
emerged from the dysarthric group included
the following perceived barriers. The first bar-
rier related to work conditions. Individuals with
dysarthria reported barriers in communicating a
message forcefully, having to speak efficiently
and accurately, and being able to get a point
across convincingly. These perceived barriers
perhaps relate directly to subsystem impair-
ments such as hypophonia, and/or articula-
tory/prosodic alterations (b310, b320, b330).
Aspects of the physical environment also
can affect speech intelligibility. Lighting, noise,
proximity of the listener to the speaker, and the
communication environment can represent
potential variables contributing to the overall
intelligibility of the speaker. Although variables
related to the physical environment can be
APPLICATION OF ICF TO DYSARTHRIA/DYKSTRA ET AL 307
classified as Environmental Factors, it is impor-
tant to recognize that these variables also over-
lap with the Activity and Participation
dimensions of ICF. Garcia et al33 identified
physical barriers related to difficulty communi-
cating in a noisy work setting, and using com-
munication devices such as the telephone and
voicemail. Finally, the number and type of
speakers were reported to be barriers to com-
munication. Specifically, interacting in large
meetings, and speaking to strangers and to
people in positions of authority were reported
as barriers by individuals with dysarthria.33
One interesting finding to emerge from the
study by Garcia et al33 was that individuals with
dysarthria identified the attitudes and percep-
tions of others as barriers. A lack of respect and a
tendency for others to assume decreased intelli-
gence were common themes reported. This
finding emphasizes the importance of expand-
ing our conceptualization of reduced speech
intelligibility in dysarthria. A judgment of
one’s speech intelligibility based on traditional,
decontextualized estimates (i.e., a severity rating
obtained from a single-word or sentence intelli-
gibility test) provides valuable information, but
it does not capture the essence of the disable-
ment process associated with dysarthria. In
addition to an individual’s occupational context
and setting, it also is important to examine other
environmental factors that can facilitate or hin-
der the functioning of an individual with dys-
arthria, such as situational difficulty, or the
perceived reactions of others. Yorkston et al34
investigated how individuals with dysarthria
experience their disability. Using a 100-item
questionnaire, 33 individuals with dysarthria
representing mild (sentence production is intel-
ligible), moderate (sentence intelligibility 50 to
95%), and severe (less than 50% intelligible)
dysarthria participated in the study. Participants
rated contexts dealing with situational difficulty
(i.e., partner familiarity, size of audience, de-
mand for intelligibility, demand for speed, emo-
tional load, and environmental adversity) and
compensatory strategies (i.e., improved produc-
tion, environmental modification, avoidance,
message modification, and partner instruction).
They also rated perceived reaction of others.
These included being helpful (a beneficial re-
sponse by communication partners), solicitous
308 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
(excessive concern for the speaker’s welfare), or
punishing (penalizing the speaker with dysarth-
ria). No differences were found among groups
for situational difficulty. Results for compensa-
tory strategies revealed that all participants felt
that improved production was the most benefi-
cial strategy. Interestingly, under the category
dealing with the perception of others, individ-
uals with severe dysarthria felt that others were
more helpful, more solicitous, and more punish-
ing than did the individuals studied with mild or
moderate dysarthria. This finding suggests that
individuals with severe dysarthria differ in their
perception of the reaction of others to their
dysarthria.34 One other finding to emerge
from this study was an apparent mismatch
between severity level and perception of disabil-
ity in an individual with a diagnosis of
Parkinson’s disease. Although this individual
had speech that was judged to be more than
95% intelligible, he reported greater difficulty
with items related to situational difficulty than
other subjects with severe dysarthria. Likewise,
an individual with severe dysarthria reported
almost no situational difficulty. This apparent
discordant finding is a poignant example of
how the biopsychosocial model of the ICF can
explain disruptions in functioning associated
with a health condition. This example demon-
strates both how Activity limitations and/or
Participation restrictions can occur in the rela-
tive absence of an impairment, and conversely,
how a severe impairment can result in minimal
Activity limitations and/or Participation restric-
tions.
Additional Environmental Factors relate to
the support and attitudes of the family, friends,
acquaintances, peers, and/or health professio-
nals of the individual with dysarthria. A poor
understanding of dysarthria and the associated
reductions in speech intelligibility can result in
limited support and negative attitudes toward
the individual with the communication disor-
der. Likewise, a supportive social network can
foster more positive attitudes toward under-
standing the consequences of reduced speech
intelligibility. It also is important to be cogni-
zant that these factors can contribute differ-
entially across individuals with dysarthria with
similar speech intelligibility profiles. For in-
stance, consider an example wherein two indi-
2007
viduals with similar speech intelligibility
profiles live in two different communities.
The first community has created a social policy
that provides a support group to individuals
with dysarthria, as well as universal access to
speech-language pathology services. One indi-
rect byproduct of this social policy could be an
increased public awareness of the difficulties
associated with reduced speech intelligibility,
which results in less discriminatory attitudes to
individuals with this communication disorder.
In the other community, no such social policies
exist, access to support and service is difficult,
and there is limited public awareness related to
dysarthria. Therefore, it is conceivable that the
individual with dysarthria in the first commun-
ity could report less impact of his/her commu-
nication disorder, whereas the second
individual could report a greater impact of
having reduced speech intelligibility due to
barriers in the community, despite having a
similar health condition. Therefore, different
societal environments can have very different
impacts on the same individual.
Environmental factors are multifaceted. It
is difficult, therefore, to draw specific conclu-
sions regarding the effect of environmental
factors on speech intelligibility in individuals
with dysarthria. Despite these difficulties, it is
necessary to acknowledge that environmental
factors can impact significantly and differen-
tially an individual’s disability and functioning.
If speech-language pathologists are to adopt a
comprehensive view of speech intelligibility in
dysarthria, it is important to shift our attention
from traditional estimates of severity to an
evaluation of speech intelligibility that ac-
knowledges an individual’s life context as an
important aspect of their communication dis-
order and their overall speech intelligibility.
Personal Factors
Personal factors are not classified within the
ICF, but they are included in the conceptual
model because they likely contribute and have
an impact on the individual’s health condition.
Personal factors represent features of the indi-
vidual that are not related to the health con-
dition and can interact with an individual’s
functioning at any level of disability (i.e.,

Body Functions, Body Structures, Activities
and Participation). Factors include, but are
not limited to age, sex, fitness, lifestyle, coping
styles, upbringing, education, profession, past
or current experiences, and/or social experien-
ces.15
There appear to be no published studies in
the literature that have examined specifically
how Personal Factors influence dysarthric
speech intelligibility. Obtaining information
on Personal Factors is important when con-
ceptualizing speech intelligibility in dysarthria,
because an examination of these factors has the
potential to shed light on the impact and
consequences of having reduced speech intelli-
gibility associated with dysarthria. Again, it is
conceivable that different personal factors such
as coping style, age, education, accent, upbring-
ing, sex, or social background for example may
heavily influence the impact of having reduced
speech intelligibility associated with dysarthria
for both the speaker and the listener. Personal
factors, therefore, are important to explore
during clinical interventions or research studies
because these personal elements may influence
the outcome of interventions or research find-
ings. Specifically, exploring personal factors
may help clinicians and researchers understand
the impact of these factors on treatment effec-
tiveness. Finally, this information may aid in
the development of a broader conceptualization
of the impact of having reduced speech intelli-
gibility secondary to dysarthria.
CASE EXAMPLE
History
Bill is 75 years old and he was diagnosed
recently with PD. Bill is a retired farmer in a
rural community with a strong support network
of family and friends. He was referred for a
motor speech assessment due to increased dif-
ficulty with family and friends understanding
his conversational attempts. Bill’s speech was
characteristic of hypokinetic dysarthria, which
is associated classically with PD.
Hypokinetic dysarthria is associated with
basal ganglia pathology. Neurochemically,
there is a loss of dopaminergic cells in the
substantia nigra (pars compacta; SNpc). Death
APPLICATION OF ICF TO DYSARTHRIA/DYKSTRA ET AL 309
of dopaminergic cells in the SNpc results in a
loss of dopamine content in the striatum and
yields an imbalance of dopamine and acetylcho-
line. Interestingly, it is estimated that the onset
of motor symptoms do not occur until 70 to
90% of dopaminergic nerve cells are de-
stroyed,35 suggesting highly redundant neuro-
nal and neurochemical systems.
Body Structures and Functions
During the clinical assessment, Bill demon-
strated a mask-like facial expression (b7356).
No structural abnormalities of the oral structure
(s320), including the lips, jaw, and tongue, were
evident during assessment at rest. Nasoendo-
scopic assessment of the laryngeal musculature
(s340) indicated normal appearance of laryngeal
tissue with the exception of mild bowing of the
true vocal folds at rest. Tissue color and shape
were within normal limits. During lingual and
labial movements, a mild reduction in range of
movement was demonstrated. Imprecise con-
sonant articulation (b320) was evident during
spontaneous speech attempts. Pitch and loud-
ness (b310) were judged to be reduced, with the
speaker demonstrating low volume, a variable
rate, and monotonous speech (b3303).
Activities
Results from the shortened version of the SIT22
resulted in a sentence intelligibility score of
85% in a standard, quiet testing condition.
Speaking rate was mildly decreased (170 words
per minute) when compared with the expected
normal value of 190 words per minute. Given
that the clinical assessment revealed Bill’s
speech was hypophonic, the SIT also was ad-
ministered to Bill in background noise (65 dB
multitalker noise). Results of this administra-
tion revealed an intelligibility score of 53%.
Participation
Administration of the CETI-M31 indicated
that both Bill and his family perceived that he
was intelligible in general conversational situa-
tions in which he spoke one on one (d330).
However, he did self-report increased difficulty
in situations with being understood when there
310 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 28, NUMBER 4
was increased background noise. He noticed
specific problems when meeting his friends at
the local meeting area to play cards or when
attending church gatherings. The ASHA QCL
also was administered to Bill to assess the
impact of reduced intelligibility on his commu-
nication-related quality of life (QoL). Results
of the QCL revealed that Bill reported reduc-
tions in QoL related to his relative ease of
communication, speech intelligibility, and con-
fidence communicating effectively. During
therapy sessions, use of a portable amplifier
was attempted, resulting in increased success
with communication in the presence of back-
ground noise. For example, his speech intelli-
gibility score (SIT) increased from 53 to 79%
when using the voice amplifier while speaking
in background noise (65 dB). Following ther-
apy, the CETI-M and QCL were re-adminis-
tered. Based on the CETI-M, Bill self-reported
more effective communication in noisy settings
and before a group. Bill also self-reported
improved QoL related to his relative ease of
communication, intelligibility, and confidence
communicating when using his voice amplifier,
resulting in increased attendance at his weekly
card event.
Environmental and Personal Factors
This individual had a great support network of
friends and family. Bill’s family and friends not
only accepted but also encouraged him to use
his amplifier when they were together. Bill was
motivated by his own personal drive to main-
tain connections with his fiends and family,
resulting in increased usage of an alternative
communication system during conversations.
SUMMARY
The conceptual framework of the ICF promotes
and facilitates an awareness of the multidimen-
sional nature of disablement, and allows us to
examine critically the current status of the con-
ceptualization of speech intelligibility in speak-
ers with dysarthria. This framework helps to
facilitate a broad understanding of the complex
nature of dysarthric speech intelligibility rang-
ing from the neuroanatomical and physiological
substrates contributing to reduced speech intel-
2007
ligibility to the effects of this type of commu-
nication disorder on an individual’s functioning
in society and beyond. Approaching dysarthric
speech intelligibility from this perspective
presents us with challenges, but has the poten-
tial to aid in broadening our research questions,
help to determine where gaps exist in our
clinical and research literature, and ultimately,
facilitate meaningful rehabilitation practices for
the individual with dysarthria.
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