AJSLP
Research Article
Articulatory Range of Movement in
Individuals With Dysarthria Secondary
to Amyotrophic Lateral Sclerosis
Jimin Leea and Michael Bella
Purpose: The current study examined overall articulatory
range of movement (ROM) in individuals with amyotrophic
lateral sclerosis (ALS). Differential involvement of articulators
was also tested using articulatory working space in individuals
with varying degrees of dysarthria severity and in typically
aging individuals. A strong association between overall
articulatory ROM and severity measures among individuals
with ALS was hypothesized. In addition, it was hypothesized
that differential involvement of articulators would be
detected using overall articulatory ROM measures.
Method: Twenty-two speakers with dysarthria secondary to
ALS and 22 typically aging speakers participated. Speech
intelligibility and speaking rate were used as indices of
severity. Movement range and overall articulatory working
space area (convex hull) of the tongue, lower lip, and jaw
were each measured by electromagnetic articulography
while the speakers produced the Rainbow Passage.
Results: Tongue convex hull size was significantly
correlated with both indices of severity. A significant
A
myotrophic lateral sclerosis (ALS) is a degenera-
tive motor neuron disease. Regardless of the
onset type of the disease, up to 95% of people
with ALS lose their speech function (Ball, Beukelman, &
Bardach, 2007; Ball, Beukelman, & Pattee, 2004). Among
the many physical functions, the loss of speech function
has been found to influence quality of life most signifi-
cantly (Felgoise, Zaccheo, Duff, & Simmons, 2016). Much
effort has been expended to understand articulatory dys-
function in individuals with ALS to develop effective as-
sessment and intervention plans. The current study adds
to this effort by examining the overall articulatory range
a
Department of Communication Sciences and Disorders, The
Pennsylvania State University, University Park
Correspondence to Jimin Lee: JXL91@psu.edu
Editor-in-Chief: Julie Barkmeier-Kraemer
Editor: Kristie Spencer
Received May 11, 2017
Revision received October 10, 2017
Accepted February 20, 2018
https://doi.org/10.1044/2018_AJSLP-17-0064
996 American Journal of Speech-Language Pathology • Vol. 27 • 996–1009 • August 2018 • Copyright © 2018 American Speech-Language-Hearing Association
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
interaction between articulators and groups was
observed. Individuals with severe dysarthria had
reduced tongue convex hull size and exaggerated
lower lip convex hull size. ROM in the anterior–
posterior dimension showed a more notable differential
involvement pattern than ROM in the superior–inferior
dimension. Results in the area under a receiver operating
characteristic curve analysis revealed group-specific
ROM sensitivity.
Conclusions: The findings indicate that tongue ROM is
reduced in individuals with more severe dysarthria when
estimated using a standardized paragraph containing
all American English phonemes. The articulatory working
space measure could be useful for estimating speech
dysfunction in ALS. ROM of the tongue decreases, but
ROM of the lower lip and jaw each increase in individuals
with severe dysarthria. Differential involvement of the
articulators in the anterior–posterior dimension needs to
be further investigated.
of movement (ROM) during speech production of individ-
uals with ALS.
Previous research has shown smaller acoustic vowel
spaces in individuals with dysarthria. These smaller acous-
tic vowel spaces were found to be sensitive to severity
of dysarthria in individuals with various neurological con-
ditions including ALS (Weismer, Jeng, Laures, Kent, &
Kent, 2001). These findings have been interpreted as repre-
sentations of spatial articulatory characteristics such as
smaller articulatory working space. However, previous find-
ings in spatial articulatory kinematic characteristics have
been inconsistent in individuals with ALS depending on the
speech stimuli (e.g., /i/ vs. /æ/) as well as the types of spatial
measures (Lee, Littlejohn, & Simmons, 2017; Weismer,
Yunusova, & Bunton, 2012; Yunusova, Weismer, Westbury,
& Lindstrom, 2008). To examine spatial characteristics in
individuals with dysarthria secondary to ALS, the current
study employed stimuli containing all vowels and consonants
in American English (AE) and a working space measure.
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
 Furthermore, articulatory working space was tested for its
sensitivity to differential involvement of articulators (e.g.,
greater involvement of the tongue than the jaw). Testing
for the differential involvement of articulators is critical
because it would influence how individuals with ALS pro-
duce speech and compensate for articulatory impairment.
As this information cannot be obtained via acoustic data,
an articulatory kinematic approach is necessary for the pur-
pose. The findings in the current study can further validate
and expand on the previous interpretations of acoustic
and articulatory kinematic data regarding individuals with
ALS. The following section describes the motivation and
justification of the study in detail.
Speech Characteristics in ALS
The perceptual characteristics of speech in individ-
uals with dysarthria secondary to ALS include slow speak-
ing rate, imprecise consonants and vowels, hypernasality,
and a harsh voice (Yorkston, Beukelman, & Bell, 1999,
pp. 162–166). Imprecise sound production, which relates to
the articulatory subsystem, was found to negatively affect
the speech intelligibility of these individuals most (Rong
et al., 2016). Thus, to understand speech dysfunction in
individuals with ALS, characteristics of speech acoustics
and articulatory kinematics have been examined. Acoustic
studies showed longer segment duration as well as reduced
acoustic vowel working space, formant transition extent,
and second formant slope (Kent et al., 1992; Weismer
et al., 2001). Traditionally, these acoustic findings in indi-
viduals with ALS have been used to interpret articulatory
dysfunction. For example, the reduced second formant
slope seems to indicate slower changes in vocal tract
configuration. This finding has been confirmed by articu-
latory kinematic studies that revealed slower speed of artic-
ulators, particularly the tongue, in individuals with ALS
(Green et al., 2013).
Reduced acoustic vowel space and formant transition
extent have been interpreted as reflecting limited articula-
tory ROM in individuals with ALS. Unlike the consistent
findings of slower articulatory speeds in ALS, findings in
spatial articulatory kinematic characteristics, such as artic-
ulatory displacements, have varied depending on target
stimuli. Previous research showed that articulatory move-
ment distance findings differ based on target stimuli
(Yunusova et al., 2008). In Yunusova et al. (2008), among
10 different consonant–vowel–consonant words, only “cat”
and “dog” showed significant differences for tongue move-
ment between individuals with ALS and neurologically
healthy speakers. The group difference based on the dis-
tance measure used did not generalize across all word stim-
uli examined. In other words, depending on the target
stimuli, a group difference may or may not be detected
with an articulatory movement distance measure. Recently,
Shellikeri and her colleagues (2016) examined articulatory
kinematic characteristics using a sentence filled with bila-
bial sounds. Movement ranges of the tongue and jaw,
measured as Euclidean distances, were not significantly
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
different between individuals with and without ALS in the
study. While discussing the findings, the authors speculated
about the influence of the stimuli.
Different sound productions require different articu-
latory gestures. Particular gestures or coordination patterns
of articulators could be more challenging than others for
individuals with dysarthria (Weismer, Martin, Kent, &
Kent, 1992). On the basis of previous acoustic and kine-
matic studies, it has been speculated that words requiring a
greater rate of vocal tract changes such as larger and faster
movements would be more affected in individuals with dys-
arthria (Kim, Weismer, Kent, & Duffy, 2009; Yunusova
et al., 2008). Although this has not been tested, it is sup-
ported by the slower speaking rate and limited formant
movement observed in speakers with dysarthria. In addi-
tion, a recent study suggested that words that require
greater movement in the anterior–posterior dimension can
be challenging for individuals with dysarthria secondary
to ALS (Lee, Bell, & Simmons, 2017). Further research is
needed for a clearer understanding of sound-specific find-
ings in individuals with dysarthria. Overall, target stimuli
influence the articulatory movement characteristics of indi-
viduals with ALS.
In addition to movement distance, articulatory work-
ing space area has been examined in individuals with ALS.
Articulatory working space area can be used as a measure
of tongue ROM during speech production. A preliminary
study examined tongue kinematic vowel space in 11 indi-
viduals with ALS by measuring tongue location during the
vowels /i, u, ɑ, æ/ (Lee, Littlejohn, et al., 2017). The target
stimuli and data extraction segment of this study replicated
the approach used in acoustic studies. In other words, a
single point in time (temporal midpoint of the vowel dura-
tion) was chosen to represent the vowel, as in the con-
struction of vowel spaces in previous studies. In the study,
kinematic vowel space data were correlated with speech
intelligibility (Lee, Littlejohn, et al., 2017). However, the
tongue kinematic vowel space in individuals with ALS
was not significantly different from that of neurologically
healthy speakers. Another study examined the overall
working space of the articulators during production of a
standardized paragraph. The study tested the relationship
between articulatory working space and speech dysfunction
in individuals with ALS (10), individuals with Parkinson’s
disease (22), and control speakers (20; Weismer et al., 2012).
The study descriptively showed a smaller tongue working
space in individuals with ALS compared with the control
group. In addition, a strong association was observed
between working space size and tongue movement speed,
which itself had a very high correlation to speech intelligi-
bility. In that study, the authors suggested that overall
working space of articulators has the potential to be a good
index of the neuromotor integrity of an individual’s speech
mechanism.
The current study tested articulatory working space
area’s potential sensitivity to speech dysfunction in ALS.
It is clear that speech stimuli and type of spatial kine-
matic variables can influence findings when examining
Lee & Bell: Articulatory Range of Movement in ALS 997
 articulatory kinematic characteristics in individuals with
ALS. Thus, replicating the idea presented by Weismer
et al. (2012), a standardized paragraph (Rainbow Passage)
containing all vowels and phonemes in AE was chosen to
represent overall articulatory working space area during
connected speech production.
Differential Involvement of Articulators in ALS
Differential involvement of articulators has been
claimed to be a characteristic of dysarthria in ALS. Previ-
ous findings regarding differential involvement of articu-
lators in individuals with ALS showed earlier and more
severe involvement of the tongue than the lips and jaw
(Carpenter, McDonald, & Howard, 1977; DePaul, Abbs,
Caligiuri, Gracco, & Brooks, 1988; Lawyer & Netsky,
1953; Shellikeri et al., 2016). Differential involvement of
articulators in ALS has often been examined via nonspeech
tasks, and it has been identified at different levels (e.g.,
examination of motor nuclei vs. articulator strength) across
individuals with ALS. Neuroanatomical examination of
cranial nerve nuclei showed that hypoglossal nuclei are more
affected by the disease compared with trigeminal nuclei in
individuals with ALS (Lawyer & Netsky, 1953). Previous
studies examining the strength of articulators also showed
that the tongue is more involved than the jaw and lips (DePaul
& Abbs, 1987; DePaul et al., 1988; DePaul & Brooks, 1993;
Langmore & Lehman, 1994).
Analyses of the site of primary symptoms also showed
greater impairment of the tongue than other articulators
(Carpenter et al., 1977). Of the 128 patients with ALS who
presented with head and neck symptoms, the tongue was
the most common site of symptoms. The primary symptom
of the tongue in the study was difficulty in speech produc-
tion. During physical examination, weakness and fascicula-
tion of the tongue were noticed in 66% and 54% of the
patients, respectively. Overall, tongue function is impaired
most severely, and jaw as well as lip functions are relatively
preserved. Studies that reported differential involvement
of articulators were based on testing between-individual dif-
ferences and thus were cross-sectional analyses.
A few studies have tested differential involvement
of articulators based on speech tasks using articulatory
kinematics. Early descriptive articulatory kinematic studies
showed differential involvement of articulators in a few
individuals with ALS (Hirose, Kiritani, & Sawashima, 1982a,
1982b; Hirose, Kiritani, Ushijima, & Sawashima, 1978).
These early descriptive studies showed slower movement of
articulators as well as atypical movements such as greater
movement distance of the jaw in individuals with ALS com-
pared with neurologically healthy speakers. Spatial charac-
teristics of articulatory movement were examined during
various vowel productions in a later study (Yunusova et al.,
2008). As noted above, the study showed different findings
depending on the target stimuli. Among the 10 words, total
movement distance of the jaw was greater in individuals
with ALS compared with neurologically healthy speakers
in only two words. In longitudinal analyses, differential
998 American Journal of Speech-Language Pathology • Vol. 27 • 996–1009 • August 2018
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
involvement of articulators was more clearly detected
(Shellikeri et al., 2016). In that study, tongue movement
range decreased in size, but jaw movement range did not.
Interestingly, differential involvement of articulators
was not detected in the cross-sectional analyses of the
same study (Shellikeri et al., 2016). This could be due to
the inherent variability of articulatory kinematic mea-
sures particularly for spatial measures in cross-sectional
comparisons. In addition, variability of articulatory kine-
matic data may also be related to variation in target stim-
uli and kinematic measurement(s) as described above.
Further understanding of differential involvement
of articulators is necessary to understand articulatory dys-
function in ALS. These articulators interact for speech pro-
duction. In previous studies, when larger-than-normal jaw
distance and reduced tongue distance were observed, po-
tential compensatory behavior of the jaw has been specu-
lated (Shellikeri et al., 2016; Yunusova et al., 2008). As
this observation was stimulus specific, differential spatial
characteristics among articulators can be examined further
by using stimuli that contain both vowels and consonants.
In the current study, overall articulatory working spaces
for different articulators were examined across individuals
with ALS and healthy controls to detect potential differen-
tial involvement of articulators.
In summary, overall working space areas of the
tongue, lower lip, and jaw were examined in individuals
with ALS and typically aging individuals. The following
questions and hypotheses were explored:
1. How is articulatory ROM related to severity of
speech involvement in individuals with ALS? It was
hypothesized that, for the tongue, a smaller articula-
tory ROM would be associated with greater severity
as measured by speech intelligibility and speaking
rate. For the lower lip and jaw, it was hypothesized
that a larger articulatory ROM would be associated
with greater severity in individuals with ALS.
2. Is the articulatory ROM pattern across articulators
consistent among individuals with different severities
of dysarthria secondary to ALS and typically aging
speakers (severe vs. mild vs. control)? It was hypothe-
sized that reduced tongue ROM and exaggerated lip
and jaw ROMs would be present in all severity groups
in individuals with dysarthria secondary to ALS.
Method
Speakers
Forty-four speakers, including 22 speakers with dys-
arthria secondary to ALS and 22 typically aging adults,
participated in the study. The speakers with ALS included
11 men and 11 women (M = 62.8 years old, SD = 9 years
old). The typically aging participants included 12 women
and 10 men (M = 63 years old, SD = 7.4 years old).
Table 1 shows characteristics of the speakers with
ALS. To quantify speech function, speech intelligibility and
speaking rate (words per minute [wpm]) were measured.
 In ALS, speaking rate has been identified as an index of
speech function as well as speech intelligibility. In fact,
speaking rate changes more linearly with speech function
declination than speech intelligibility in individuals with
ALS (Yorkston, Strand, Miller, Hillel, & Smith, 1993).
Each speaker completed the Speech Intelligibility Test (SIT;
Beukelman, Yorkston, Hakel, & Dorsey, 2007). Using the
data, speech intelligibility and speaking rate of each speaker
were obtained. Typical speaking rate in neurologically
healthy individuals is approximately 190 wpm based on
this protocol (Yorkston, Beukelman, Hakel, & Dorsey,
1996). Using the speaking rate and speech intelligibility
data, speakers with dysarthria secondary to ALS were fur-
ther divided into two severity groups: severe (13 speakers)
and mild (nine speakers). Speakers with a speaking rate
faster than 100 wpm and with speech intelligibility above
90% were assigned to the mild group. This cutoff for speak-
ing rate was chosen because individuals with ALS experi-
ence rapid decline of speech function when they reach
a speaking rate between 100 and 120 wpm (Ball et al., 2007;
Ball, Beukelman, & Pattee, 2002; Ball, Willis, Beukelman,
& Pattee, 2001; Yorkston et al., 1993). The cutoff for speech
intelligibility was used to ensure that speakers with a fast
speaking rate and low speech intelligibility (e.g., PALS16)
could be assigned to the accurate severity group. Each
speaker with ALS completed the ALS Functional Rating
Scale–Revised (Cederbaum et al., 1999). From the ALS
Functional Rating Scale–Revised score, a bulbar subscore
—which combines speech, salivation, and swallowing func-
tion scores—was also obtained for each participant. The
maximum bulbar subscore is 12. None of the participants
had received speech-language intervention targeting
dysarthria.
Speakers with ALS were recruited from the ALS
Clinic at Penn State Hershey Medical Center. They all
met El Escorial criteria for definite, probable, or laboratory-
supported probable ALS (Brooks, Miller, Swash, & Munsat,
2000). Each participant was a native speaker of AE and
from the Mid-Atlantic region in the United States. Among
the 22 speakers with ALS, 21 passed a hearing screening at
250, 500, 1000, and 2000 Hz at 35 dB in at least one ear.
One speaker with ALS (PALS20) who was 80 years old had
hearing loss and responded to the pure tone at 2000 Hz at
65 dB in his better ear. He was not using hearing aids.
The typically aging speaker group (control group)
had an average speech intelligibility score and speaking rate
of 95% (SD = 2.7%) and 184 wpm (SD = 21 wpm), respec-
tively. Each typically aging speaker in the current study
was a native speaker of AE and from the Mid-Atlantic
region in the United States. Twenty-one typically aging
speakers passed a hearing screening at 250, 500, 1000, and
2000 Hz at a level of 35 dB in at least one ear. One typically
aging speaker who was gender and age matched to PALS20
used hearing aids. He passed the screening while using hear-
ing aids. Per self-report, the typically aging speakers did
not have any known speech, language, or neurological dis-
orders. All participants provided informed consent.
Listeners
Three listeners were assigned to each speaker with
dysarthria secondary to ALS. Each listener completed a

Table 1. Characteristics of individuals with dysarthria secondary to amyotrophic lateral sclerosis (ALS).

Time since onset ALS Functional Speech

Participant of dysarthria Rating Scale–Revised ALSFRS-R bulbar Intelligibility Speaking
code Age Gender symptom (months) (ALSFRS-R) total subscore Test score (%) rate (wpm)

PALS1 66 Female 44 20 2 7 48
PALS2 64 Female 19 39 5 26 57
PALS3 43 Female 120 24 8 59 65
PALS4 47 Male 36 24 3 10 70
PALS5 63 Female 11 12 4 12 70
PALS6 66 Female 5 32 6 12 77
PALS7 64 Male 51 40 6 80 80
PALS8 66 Female 33 37 5 94 83
PALS9 48 Male 10 34 9 70 88
PALS10 69 Female 20 35 7 71 94
PALS11 71 Female 15 39 9 93 94
PALS12 50 Male 16 25 9 43 100
PALS13 67 Male 201 23 6 94 102
PALS14 64 Male 37 44 8 92 108
PALS15 64 Female 15 45 9 91 109
PALS16 68 Male 8 9 7 68 118
PALS17 60 Male 49 35 10 92 124
PALS18 65 Male 12 45 9 90 126
PALS19 61 Female 5 29 9 95 131
PALS20 80 Male 1 37 6 95 131
PALS21 76 Female 18 29 9 98 133
PALS22 60 Male 9 42 9 98 202

Note. wpm = words per minute.

Lee & Bell: Articulatory Range of Movement in ALS 999

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 series of perceptual tasks for a larger project, including the
SIT. The session took approximately 1 hr 15 min. Each
listener listened to one speaker (Lee, Hustad, & Weismer,
2014). For interrater reliability, when a difference in speech
intelligibility scores greater than 10% was observed among
the three listeners, the outlier was located and a new lis-
tener was recruited to replace the data. One hundred fifty-
five listeners participated in the study, and data collected
from 132 listeners were used after the implementation of
this rule. The average age of the 132 listeners was 21.8 years
(SD = 3.6 years). Each listener (a) was a native speaker of
AE; (b) had no known speech, language, and cognitive
disorders per self-report; (c) passed a hearing screening at
250, 500, 1000, 2000, 4000, and 6000 Hz at 25 dB bilater-
ally; and (d) did not have substantial experience communi-
cating with individuals with motor speech disorders. To
examine the interjudge reliability in the SIT data, an intra-
class correlation coefficient was calculated using a one-way
random model (Neel & Palmer, 2012; Tjaden, Sussman,
& Wilding, 2014). The intraclass correlation coefficient values
of single and average measures were .986 and .995, respec-
tively ( p < .001).
Procedures
Speech Production
The target stimuli for the current study were the first
six sentences of the Rainbow Passage (Fairbanks, 1960).
A three-dimensional electromagnetic articulography sys-
tem (Wave, NDI) simultaneously collected kinematic and
acoustic data. A professional-quality headset microphone
was placed 2 in. from the corner of the speaker’s mouth.
One reference sensor was attached to the forehead of speakers.
Four movement sensors were attached after placement
of the reference sensor. Sensors were attached to the ton-
gue tip (approximately 10 mm away from the tongue apex),
tongue body (approximately 15 mm away from the tongue
tip sensor), lower lip, and jaw along the midsagittal plane. In
addition, each speaker’s bite (occlusal) plane data were
collected to rotate the kinematic data accordingly. In the
current study, tongue and lip data were not decoupled from
the jaw to represent the natural speaking style. Thus, data
from these articulators contain the influence of jaw move-
ment. A sampling rate of 100 Hz and a 10-Hz low-pass
filter were used.
Data Analyses
Identifying Temporal Boundaries of Target Stimuli
Temporal boundaries of the target stimuli were
identified using waveform and wideband spectrographic
displays in TF32 (Milenkovic, 2001). For the current
study, pauses over 150 ms as well as audible swallowing
and breathing segments were excluded (Tsao & Weismer,
1997). This rule was employed to contain only speech-
production–related articulatory movement in the kinematic
data.
1000 American Journal of Speech-Language Pathology • Vol. 27 • 996–1009 • August 2018
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Kinematic Analyses
Kinematic data were rotated and translated using the
bite plane data and a customized R code (R Core Team,
2014). After translation, the origin of the coordinate sys-
tem (0,0,0) matched the midsagittal lower edge of the max-
illary central incisor. Within the temporal boundaries of
the target stimuli, kinematic data from sensors attached
to the tongue tip, tongue body, lower lip, and jaw were ex-
tracted. Each trajectory was manually checked for tracking
errors. The following kinematic variables were collected
for each articulator: convex hull area in square millimeters,
ROM in the anterior–posterior dimension, and ROM in
the superior–inferior dimension. Figure 1 illustrates each
kinematic variable for tongue body movement. Convex
hull area was employed to quantify the area covered by artic-
ulatory movement (i.e., overall working space area) during
target stimuli production. The convex hull area of each artic-
ulator was calculated using MATLAB (Mathworks, 2015).
Experimental Design and Analysis
Pearson correlation coefficients were used to examine
relationships between kinematic variables and both speech
intelligibility and speaking rate in individuals with dysar-
thria secondary to ALS. To test differential involvement
of articulators across the groups, a split-plot analysis of
variance (ANOVA) was performed. Four articulators (ton-
gue tip, tongue body, lower lip, and jaw) and three groups
(severe, mild, and control) were examined in the study.
The group was a between-subject effect, and the articulator
and Articulator × Group interaction were within-subject
effects. Statistical results of the interactions between a
group and each articulator were used to determine the
presence of differential involvement of articulators across
Figure 1. Range of movement (ROM) variables: convex hull area,
ROM in the anterior–posterior dimension, and ROM in the superior–
inferior dimension.
 the groups. If Articulator × Group interaction was signifi-
cant with an alpha level of .05, Tukey post hoc tests were
used for pairwise comparisons of the groups for each articu-
lator. Sets of analyses were completed for each of the
three ROM measurements used: convex hull, ROM in
the anterior–posterior dimension, and ROM in the superior–
inferior dimension. Main articulator effects were not of
interest in the current study. In addition, a receiver operating
characteristic (ROC) curve analysis was performed to test
the sensitivity of ROM measures to each severity group.
Results
Correlates of Speech Intelligibility
and Speaking Rate
Table 2 shows the results of correlational analyses.
In the 22 speakers with dysarthria secondary to ALS, only
convex hull areas of the tongue tip and body were found
to be significantly correlated with both speech intelligibility
and speaking rate. In addition, tongue body movement
range in the superior–inferior dimension was significantly
correlated with speaking rate. None of the other movement
range kinematic variables were significantly correlated with
speech intelligibility. Overall, individuals with more severe
dysarthria showed reduced tongue convex hull size. Figure 2
shows the scatter plot of speech intelligibility and tongue
tip and body convex hull sizes. Figure 3 shows the scatter
plot of speaking rate and the three significant correlates:
tongue tip and body convex hull sizes and tongue body
movement range in the superior–inferior dimension. Data
from typically aging speakers were added to Figures 2
and 3 for reference.
Interaction Between Articulator
Involvement and Groups
Figures 4–6 show the ROM trends of each articu-
lator across groups. Figures 4–6 show convex hull size,
ROM in the anterior–posterior dimension, and ROM in
the superior–inferior dimension, respectively. These three
variables were used as dependent variables in the split-plot
ANOVA. Mauchly’s test showed that the assumption of
sphericity was violated; thus, degrees of freedom were
corrected using Greenhouse–Geisser estimates of sphericity.
In the following section, the statistical findings are described
according to each dependent measure.
Convex Hull (Overall ROM)
The split-plot ANOVA showed a significant interac-
tion between articulators and groups for convex hull size,
F(3.38, 69.36) = 18.5, p < .001, ηp2 = .475. Table 3 shows
a summary of the Tukey post hoc test results. The Tukey
post hoc analyses showed significantly decreased tongue
tip and body convex hull sizes and significantly increased
lower lip convex hull size in the severe group compared
with the control group.
ROM in the Anterior–Posterior Dimension
A significant interaction between articulators and
groups was revealed for ROM in the anterior–posterior
dimension, F(2.75, 56.40) = 15.7, p < .001, ηp2 = .435.
The post hoc test results showed significantly decreased
tongue tip ROM in the anterior–posterior dimension
in the severe group compared with the control group.
In addition, significantly exaggerated lower lip and jaw
ROMs in the anterior–posterior dimension were observed
in the severe and mild groups compared with the control
group.
ROM in the Superior–Inferior Dimension
A significant interaction between articulators and
groups was observed for ROM in the superior–inferior
dimension, F(4.45, 91.32) = 4.19, p = .003, ηp2 = .170.
The post hoc test results showed that lower lip ROM
in the superior–inferior dimension was significantly

Table 2. Pearson correlation coefficient values (r values) between each kinematic variable and severity indices (speech
intelligibility and speaking rate; N = 22).

Speech intelligibility Speaking rate

Variables Articulator Pearson r p Value Pearson r p Value

Convex hull area Tongue tip .51* .015 .45* .037

Tongue body .48* .024 .53* .011
Lower lip −.13 .552 −.19 .399
Jaw −.34 .124 −.23 .305
Range of movement (ROM) in the Tongue tip .40 .062 .29 .185
anterior–posterior dimension Tongue body .18 .425 .21 .346
Lower lip .01 .954 −.20 .372
Jaw −.10 .646 −.16 .476
ROM in the superior–inferior dimension Tongue tip .37 .091 .36 .098
Tongue body .35 .110 .51* .015
Lower lip −.04 .861 .10 .670
Jaw −.23 .304 .01 .959

*p < .05.

Lee & Bell: Articulatory Range of Movement in ALS 1001

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Figure 2. Scatter plots showing significant relationships between speech intelligibility and the following variables
in speakers with dysarthria secondary to amyotrophic lateral sclerosis and typically aging individuals (control):
tongue tip convex hull size and tongue body convex hull size.

exaggerated in the mild group compared with the con-
trol group.
Overall, the lower lip and jaw seem to have a simi-
lar trend that is different from the trend of the tongue
tip and body across the severity groups. Tongue tip and
body ROMs decreased but lower lip and jaw ROMs in-
creased in more severe groups. This indicates differential
involvement of articulators. As Figures 4–6 show, differ-
ential involvement of articulators seems to influence articu-
latory movement in the anterior–posterior dimension
more notably than the superior–inferior dimension, partic-
ularly for the lower lip and jaw.
ROC Curve Analysis
Table 4 shows a summary of the ROC curve analy-
sis results. A significant effect was observed in the following
variables while determining sensitivity and specificity to
the severe group: convex hull of all four articulators, lower
lip and jaw ROMs in the anterior–superior dimension,
and tongue tip and body ROMs in the superior–inferior
dimension. Specifically, a smaller tongue ROM and larger
lower lip and jaw ROMs were sensitive to the severe group.
When tested for the mild group, none of the ROM mea-
sures showed a significant effect.

1002 American Journal of Speech-Language Pathology • Vol. 27 • 996–1009 • August 2018

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Figure 3. Scatter plots showing significant relationships between speaking rate and the following variables in speakers with dysarthria secondary
to amyotrophic lateral sclerosis and typically aging individuals (control): tongue tip convex hull size, tongue body convex hull size, and tongue
body movement range in the superior–inferior dimension.

Lee & Bell: Articulatory Range of Movement in ALS 1003

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Figure 4. Group mean convex hull area size (+SE ), which represents the overall range of movement of each
articulator. The line shows the trend across the groups.

Discussion addition, by using an articulatory working space measure,

The current study examined the ROM of articulators
for speech in individuals with dysarthria secondary to ALS
and typically aging individuals. Four articulator flesh-
points were examined: tongue tip, tongue body, lower lip,
and jaw. ROM was measured while speakers produced a
standardized paragraph containing all phonemes in AE.
The results indicated that ROM of the tongue tip and body
for speech production is significantly associated with speech
intelligibility and speaking rate in individuals with ALS. The
strength of the relationship was moderate (r = .45–.53). In
the current study revealed statistically significant differential
involvement of articulators in ALS based on cross-sectional
group comparison.
In the current study, it was hypothesized that a
smaller tongue articulatory ROM and larger lip and jaw
ROMs would be observed in individuals with more severe
dysarthria as measured by speech intelligibility and speak-
ing rate. The hypothesis was supported by the data for the
tongue but not for the lip and jaw. The second hypothesis
was that reduced tongue ROM and exaggerated lip and jaw
ROMs would be present in all severity groups in individuals

Figure 5. Group mean movement range (+SE ) in the anterior–posterior dimension. The line shows the trend
across the groups.

1004 American Journal of Speech-Language Pathology • Vol. 27 • 996–1009 • August 2018

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Figure 6. Group mean movement range (+SE) in the superior–inferior dimension. The line shows the trend across the groups.

with dysarthria secondary to ALS. For tongue ROM, this
hypothesis was only supported by the data from individuals
with severe dysarthria. For lip and jaw ROMs, the hypothe-
sis was supported by the data from both individuals with
severe and mild dysarthria. Individuals with severe dysarthria
secondary to ALS produced significantly decreased tongue
ROM and exaggerated lower lip and jaw ROMs compared
with typically aging individuals. Individuals with mild dys-
arthria secondary to ALS produced significantly exagger-
ated lower lip and jaw ROMs compared with typically
aging individuals.
Articulatory Working Space Area
as an ROM Measure
Overall, the current study confirms previous specula-
tion based on acoustic studies regarding limited ROM of
articulators in individuals with dysarthria. However, this is
the case for the tongue but not the lower lip and jaw based
on the current study. The results showed that individuals
with decreased speech function due to ALS have reduced
working space of the tongue. The articulatory working
space measure is limited insofar as it provides only spatial
and not temporal characteristics of the articulators. Further-
more, the current study used a standardized paragraph
as the target stimuli. Therefore, the data provide only the
overall articulatory working space for speech production
and not information related to articulatory coordination
patterns. Regardless of this coarse-grained approach, the
measure can capture aspects of speech dysfunction includ-
ing differential involvement of articulators in ALS. The
current findings support the previous notion by Weismer
and his colleagues (2012) indicating that the articulatory
working space area measurement might be a good index
of the “gross” neuromotor integrity of an individual’s speech
mechanism.
An interesting observation in typically aging speakers
was that some reached speech intelligibility close to 100%
even with a small articulatory working space area (Figure 2).
These speakers presented with typical speaking rates as
well (between 164 and 196 wpm). The large variability of
working space in typical speakers has been observed in
previous studies (Kuo & Weismer, 2016; Tsao, Weismer, &
Iqbal, 2006; Weismer et al., 2012). A small working space

Table 3. Summary of significant kinematic range of movement (ROM) variables on group comparison Tukey post hoc test results.

Statistically significant variables Direction of group comparison effect Mean difference SE p Value

Convex hull area Tongue tip Severe < Control 137.28 37.38 .002
Tongue body Severe < Control 119.80 33.61 .003
Lower lip Control < Severe 72.61 19.87 .002
ROM in the anterior–posterior Tongue tip Severe < Control 4.14 1.64 .040
dimension Lower lip Control < Severe 5.40 1.51 .003
Lower lip Control < Mild 5.82 1.70 .004
Jaw Control < Severe 6.03 1.87 .007
Jaw Control < Mild 5.92 2.12 .021
ROM in the superior–inferior Lower lip Control < Mild 3.21 1.28 .042
dimension

Lee & Bell: Articulatory Range of Movement in ALS 1005

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 Table 4. Summary of significant range of movement (ROM) variables on the receiver operating characteristic curve analyses.

Group Statistically significant variables Area SE p Value Cut-point Sensitivity Specificity

Severe Convex hull Tongue tip 0.821 0.067 .001 245 mm2 62% 90%
Tongue body 0.793 0.081 .002 243 mm2 62% 87%
Lower lip 0.757 0.082 .008 142 mm2 69% 81%
Jaw 0.728 0.085 .018 95 mm2 92% 65%
ROM in the anterior– Lower lip 0.769 0.074 .005 13.44 mm 77% 68%
posterior dimension Jaw 0.744 0.083 .011 15.08 mm 92% 61%
ROM in the superior– Tongue tip 0.747 0.078 .010 20.02 mm 77% 68%
inferior dimension Tongue body 0.715 0.088 .026 19.97 mm 46% 90%
Mild None significant

does not necessarily result in decreased speech intelligibility
in typical speakers. This could indicate that a large articula-
tory working space is not required for good speech intelligi-
bility if the speaker retains refined motor skills. In other
words, high speech intelligibility can be maintained within
a relatively small articulatory working space if each sound
is produced with clear distinctions (Weismer, 2013). As
suggested by Weismer (2013), articulatory working space
is a coarse measure of phonetic reduction and cannot solely
explain the speech dysfunction that affects speech intelligi-
bility. Fine control of segments within the working space is
critical for intelligible speech (e.g., precise distinction be-
tween /s/ vs. /ʃ/). More fine-grained segmental data in com-
bination with overall working space need to be tested to
further understand speech dysfunction in dysarthria. In
addition, future studies on how typical speakers are dif-
ferentiating sounds in a small working space could provide
us with information regarding other strategies to enhance
speech intelligibility.
Differential Involvement of Articulators in ALS
The current study demonstrated that overall articula-
tory working space can detect differential involvement of
articulators in individuals with ALS. The consistent pat-
terns between lower lip and jaw data in the current study
could be partly due to the coupling of the articulators. In
addition, this could indicate that the effect of ALS is sim-
ilar on both jaw and lower lip functions, as noted in a pre-
vious study (Yunusova et al., 2010).
The current study showed that differential involve-
ment of the tongue and jaw can be detected by measuring
overall articulatory working space across individuals with
varying levels of dysarthria severity. A recent study showed
differential involvement of the tongue and jaw based on
articulatory movement range and speed in longitudinal anal-
yses (Shellikeri et al., 2016) but not in cross-sectional
analyses. Articulatory kinematic data on cross-sectional
analyses contain a greater room for variability such as struc-
tural differences among individuals and the heterogeneity
of ALS. In the current study, even with this type of speaker-
specific variability, the articulatory working space mea-
sure revealed significant differential involvement of the
tongue and jaw across individuals with ALS. This could be
due to the target stimuli, the selected kinematic variables,
and/or the range of dysarthria severity across individuals
in the current study.
Limited Findings in the Individuals With Mild Dysarthria
Compared with previous studies mostly involving
participants with mild dysarthria secondary to ALS, par-
ticipants with ALS in this study had a wider range of
dysarthria severity. This could have influenced both the
significant correlates and group difference findings. In
addition, the severity group cutoff could have influenced
the findings. Previous research has shown that rapid deteri-
oration of speech function occurs when individuals reach
a speaking rate between 100 and 120 wpm (Ball et al., 2001;
Yorkston et al., 1993). Depending on the design and pur-
pose of studies, the cutoff for severity group assignment
has varied. In the current study, a cutoff of 100 wpm was
used as well as 90% speech intelligibility. This could have
resulted in a different distribution of individuals in each se-
verity group compared with a study that used a cutoff of
120 wpm or above.
In the current study, differential involvement of
articulators was mostly observed between individuals with
severe dysarthria and typically aging individuals, not in
individuals with mild dysarthria. Particularly, the results
of the ROC curve showed that none of the ROM measures
were sensitive to the mild group. This could be partly due
to a small sample size of participants with a wide range of
variability (speaking rate between 102 and 202 wpm) in
the mild group. More importantly, it may indicate that the
articulatory working space measure is not sensitive to the
difference between individuals with mild dysarthria and
typically aging individuals. The small articulatory working
spaces observed in some typically aging speakers support
this speculation (Figures 2 and 3). In individuals with mild
dysarthria, examining the fine control of segments might be
more suitable to quantify the articulatory dysfunction than
the overall articulatory working space.
Compensatory Behavior vs. Manifestation of Dysfunction
If differential involvement is related to only the
degree of articulator dysfunction, not the manifestation
manner of dysfunction (e.g., reduced ROM), the work-
ing space of the jaw would be expected to be reduced in
individuals with severe dysarthria. However, individuals
with severe dysarthria showed exaggerated jaw working

1006 American Journal of Speech-Language Pathology • Vol. 27 • 996–1009 • August 2018

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 space, particularly in the anterior–posterior dimension. It
has been speculated that the exaggerated working space of
the jaw could be due to compensatory behaviors. Individ-
uals with ALS may try to compensate with their relatively
preserved jaw function to mask tongue impairment. If
this is true, the current study suggests that individuals with
severe dysarthria attempt to compensate with exaggerated
back-and-forth movement of the jaw. As speculated above,
this could be secondary to the reduced ROM of the tongue
in the anterior–posterior dimension.
The difference between the characteristics of the jaw
in individuals with ALS during speech and nonspeech tasks
also supports the idea of compensatory behaviors occur-
ring. The characteristic of the jaw, the articulator with a rel-
atively preserved function in individuals with ALS, seems to
be different between studies that used speech and nonspeech
tasks. In nonspeech task studies (e.g., articulator strength),
individuals with ALS showed much weaker tongue strength
and comparable jaw strength compared with typical speak-
ers (DePaul & Abbs, 1987; DePaul et al., 1988; DePaul &
Brooks, 1993). In other words, the jaw strength in individuals
with ALS was not greater than that of typical speakers. In
studies that used speech tasks, including the current study,
jaw movement in individuals with ALS is more exaggerated
than that of typical speakers (Hirose et al., 1982a, 1982b;
Yunusova et al., 2008). The findings from both branches of
research indicate differential involvement of articulators
but with a different direction of the effect. This could be
interpreted that, with the relatively preserved jaw function
evidenced by the comparable strength, individuals with
ALS try to compensate the reduced tongue movement with
an exaggerated jaw movement.
In natural speech, however, it is cumbersome to dif-
ferentiate compensatory behavior from the effects of the
disease. Individuals with ALS present with flaccid and/or
spastic movement. In addition, the biomechanical character-
istics of the tongue and jaw are much different (muscular
hydrostat vs. joint based). Manifestation of the observed
dysfunction in structures that are very different is likely to
depend on the type of structures as well as underlying patho-
physiology. In other words, the effect of the disease—such
as a stiff or hyperactive jaw—could also result in the exag-
gerated jaw movement.
A fundamental treatment principle of dysarthria is
adapting and maximizing preserved function to counteract
the impaired function. It remains unknown which com-
pensatory behavior of the jaw, and the resultant coordina-
tion pattern between the tongue and jaw, would enhance
speech production. Therefore, the optimal compensatory
strategy for tongue and jaw coordination needs to be inves-
tigated in individuals with ALS for maximum preserva-
tion of functional speech.
Dimension-Specific Movement
Patterns of Articulators
In the current study, ROM in each dimension was
measured in addition to overall articulatory working space.
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
When examining differential involvement of articulat-
ors, a more notable differential pattern was observed in
ROM in the anterior–posterior dimension than ROM
in the superior–inferior dimension (Figures 5 and 6).
This indicates that differential involvement observed
in overall articulatory working space area (convex hull
area) was primarily determined by the pattern observed in
the anterior–posterior dimension, not the superior–inferior
dimension.
The results showed that individuals with severe
dysarthria secondary to ALS display an exaggerated jaw
movement pattern in the anterior–posterior dimension but
not in the superior–inferior dimension. Findings regard-
ing overall articulatory working space and ROM in the
anterior–posterior dimension are noteworthy considering
that the tongue movement data are combined with the
jaw movement data in the current study. The exaggerated
jaw movement in the anterior–posterior dimension could
have masked reduced tongue movement in the same dimen-
sion. However, a reduced ROM in the anterior–posterior
dimension was still detected in tongue movement despite
being coupled with the jaw. On the other hand, in the supe-
rior–inferior dimension, jaw movement was not exagger-
ated; thus, reduced tongue movement could be more clearly
detected in individuals with severe dysarthria. Therefore,
it is speculated that the tongue movement impairment in
the anterior–posterior dimension could be more prominent
than the impairment in the superior–inferior dimension
when it is independent from jaw movement. Reduced tongue
movement in the anterior–posterior dimension was also
observed in a single-word examination in individuals
with ALS (Lee, Bell, et al., 2017). To better understand
this finding, the dimension-specific movement characteris-
tics of articulators need to be further investigated by decou-
pling tongue and jaw data in future studies. It must be
emphasized that the ROM measures in the current study
reflect overall range of motion, not articulatory trajectory
patterns. Thus, the findings regarding dimension-specific
ROM need to be considered with caution.
Clinical Significance of Articulatory Working Space
A significant correlation between a speech produc-
tion variable and a speech function outcome measure (such
as speech intelligibility) could have clinical significance in
at least two ways. First, it aids in understanding the char-
acteristics of the speech impairment present across the
severity spectrum (Weismer et al., 2012). It should be noted
that a significant correlation could also be observed be-
cause of the common disease effect underlying both speech
production and outcome variables as well. In dysarthria,
temporal characteristics of speech impairment have been
conveyed via correlations (Lee et al., 2014). For example,
a significant correlation between segment duration and
speech intelligibility in individuals with dysarthria shows
that longer duration is a characteristic of the speech impair-
ment in dysarthria. Individuals with dysarthria who have
longer segment durations have reduced speech intelligibility.
Lee & Bell: Articulatory Range of Movement in ALS 1007
 This, however, does not mean that any speech manipula-
tion resulting in a shorter duration would result in higher
intelligibility. Articulator speed is another example. It
is highly correlated with speech function outcome mea-
sures (e.g., speech intelligibility, speaking rate). This indi-
cates that slower articulator speed is a characteristic of
speech impairment in dysarthria. However, manipulat-
ing one’s speech to achieve faster speeds would not result
in higher speech function outcomes for individuals with
ALS.
Significant correlates of outcome measures could
also have clinical significance as intervention targets. In-
deed, results of correlation analyses show associations
between variables. Although not causal relationships, the
possibility remains. One long-standing compensatory inter-
vention approach for dysarthria is clear speech, which
elicits both greater intensity and exaggerated articulation.
In dysarthria secondary to some neurological conditions,
this type of approach showed benefits (Tjaden et al., 2014).
The current study clearly showed that the working space
area of the tongue is reduced in individuals with dysarthria
secondary to ALS. This spatial kinematic characteristic
may contain some potential clues for intervention based on
articulatory manipulation. In other words, if individuals
with ALS exaggerate articulatory movement (thus increas-
ing working space), it may minimize the impact of dys-
arthria. Empirical data for articulatory kinematics using
hyperarticulation are needed to test this possibility in
individuals with ALS. The findings in the current study
warrant further investigation regarding the impact of artic-
ulatory working space manipulation on speech function
outcome.
Acknowledgments
The Social Science Research Institute/Children, Youth &
Families Consortium Level I grant from the Pennsylvania State
University (awarded to the first author) funded this research. We
are grateful to the individuals with ALS who participated in this
study. We thank the Penn State Hershey ALS Clinic and Research
Center for supporting participant recruitment and Ana Daccach,
Emily Dickey, and Elizabeth Rodriguez for assistance with data
collection and analysis. Portions of the data were presented at the
2016 American Speech Language Hearing Association Convention.
References
Ball, L. J., Beukelman, D., & Bardach, L. (2007). AAC intervention
for ALS. In D. R. Beukelman, K. L. Garrett, & K. M. Yorkston
(Eds.), Augmentative communication strategies for adults with
acute or chronic medical conditions (pp. 287–316). Baltimore,
MD: Brookes.
Ball, L. J., Beukelman, D., & Pattee, G. L. (2002). Timing of
speech deterioration in people with amyotrophic lateral
sclerosis. Journal of Medical Speech-Language Pathology,
10(4), 231–235.
Ball, L. J., Beukelman, D. R., & Pattee, G. L. (2004). Acceptance
of augmentative and alternative communication technology
by persons with amyotrophic lateral sclerosis. Augmentative
and Alternative Communication, 20(2), 113–122.
1008 American Journal of Speech-Language Pathology • Vol. 27 • 996–1009 • August 2018
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Ball, L. J., Willis, A., Beukelman, D. R., & Pattee, G. L. (2001).
A protocol for identification of early bulbar signs in amyo-
trophic lateral sclerosis. Journal of the Neurological Sciences,
191(1–2), 43–53. https://doi.org/10.1016/S0022-510X(01)
00623-2
Beukelman, D., Yorkston, K., Hakel, M., & Dorsey, M. (2007).
Speech Intelligibility Test [Computer software]. Lincoln, NE:
Madonna Rehabilitation Hospital.
Brooks, B. R., Miller, R. G., Swash, M., & Munsat, T. L. (2000).
El Escorial revisited: Revised criteria for the diagnosis of
amyotrophic lateral sclerosis. Amyotrophic Lateral Sclerosis
and Other Motor Neuron Disorders, 1(5), 293–299. https://doi.
org/10.1080/146608200300079536
Carpenter, R. J., 3rd, McDonald, T. J., & Howard, F. M., Jr.
(1977). The otolaryngologic presentation of amyotrophic
lateral sclerosis. Otolaryngology, 86, 479–484.
Cederbaum, J. M., Stambler, N., Malta, E., Fuller, C., Hilt, D.,
Thurmond, B., . . . BDNF ALS Study Group. (1999). The
ALSFRS-R: A revised ALS functional rating scale that
incorporates assessments of respiratory function. Journal of
the Neurological Sciences, 169, 13–21.
DePaul, R., & Abbs, J. H. (1987). Manifestations of ALS in
the cranial motor nerves: Dynametric, neuropathologic, and
speech motor data. Neurologic Clinics, 5(2), 231–250.
DePaul, R., Abbs, J. H., Caligiuri, M., Gracco, V. L., & Brooks,
B. R. (1988). Hypoglossal, trigeminal, and facial motoneuron
involvement in amyotrophic lateral sclerosis. Neurology, 38(2),
281–283.
DePaul, R., & Brooks, B. R. (1993). Multiple orofacial indices
in amyotrophic lateral sclerosis. Journal of Speech and Hear-
ing Research, 36(6), 1158–1167. https://doi.org/10.1044/jshr.
3606.1158
Fairbanks, G. (1960). Voice and articulation drillbook (Vol. 2).
New York, NY: Harper & Row.
Felgoise, S. H., Zaccheo, V., Duff, J., & Simmons, Z. (2016).
Verbal communication impacts quality of life in patients with
amyotrophic lateral sclerosis. Amyotrophic Lateral Sclerosis
and Frontotemporal Degeneration, 17(3–4), 179–183. https://
doi.org/10.3109/21678421.2015.1125499
Green, J. R., Yunusova, Y., Kuruvilla, M. S., Wang, J., Pattee,
G. L., Synhorst, L., . . . Berry, J. D. (2013). Bulbar and speech
motor assessment in ALS: Challenges and future directions.
Amyotrophic Lateral Sclerosis and Frontotemporal Degener-
ation, 14, 494–500. https://doi.org/10.3109/21678421.2013.
817585
Hirose, H., Kiritani, S., & Sawashima, M. (1982a). Patterns of
dysarthric movement in patients with amyotrophic lateral scle-
rosis and pseudobulbar palsy. Folia Phoniatrica et Logopaedica,
34(2), 106–112.
Hirose, H., Kiritani, S., & Sawashima, M. (1982b). Velocity of
articulatory movements in normal and dysarthric subjects.
Folia Phoniatrica et Logopaedica, 34(4), 210–215.
Hirose, H., Kiritani, S., Ushijima, T., & Sawashima, M. (1978).
Analysis of abnormal articulatory dynamics in two dysarthric
patients. Journal of Speech and Hearing Disorders, 43(1), 96–105.
https://doi.org/10.1044/jshd.4301.96
Kent, J. F., Kent, R. D., Rosenbek, J. C., Weismer, G., Martin,
R., Sufit, R., & Brooks, B. R. (1992). Quantitative description
of the dysarthria in women with amyotrophic lateral sclero-
sis. Journal of Speech and Hearing Research, 35(4), 723–733.
https://doi.org/10.1044/jshr.3504.723
Kim, Y., Weismer, G., Kent, R. D., & Duffy, J. R. (2009). Statisti-
cal models of F2 slope in relation to severity of dysarthria.
Folia Phoniatrica et Logopaedica, 61(6), 329–335. https://doi.
org/10.1159/000252849
 Kuo, C., & Weismer, G. (2016). Vowel reduction across tasks
for male speakers of American English a. The Journal of the
Acoustical Society of America, 140(1), 369–383.
Langmore, S. E., & Lehman, M. E. (1994). Physiologic deficits
in the orofacial system underlying dysarthria in amyotrophic
lateral sclerosis. Journal of Speech and Hearing Research,
37(1), 28–37. https://doi.org/10.1044/jshr.3701.28
Lawyer, T., & Netsky, M. G. (1953). ALS. Clinico-anatomic
study of 53 cases. Archives of Neurology and Psychiatry, 69(2),
171–192.
Lee, J., Bell, M., & Simmons, Z. (2018). Articulatory kinematic
characteristics across the dysarthria severity spectrum in
individuals with ALS. American Journal of Speech-Language
Pathology, 27(1), 258–269. https://doi.org/10.1044/2017_
AJSLP-16-0230
Lee, J., Hustad, K. C., & Weismer, G. (2014). Predicting speech
intelligibility with a multiple speech subsystems approach in
children with cerebral palsy. Journal of Speech, Language, and
Hearing Research, 57(5), 1666–1678. https://doi.org/10.1044/
2014_JSLHR-S-13-0292
Lee, J., Littlejohn, M., & Simmons, Z. (2017). Acoustic and
tongue kinematic vowel space in speakers with and without
dysarthria. International Journal of Speech-Language Pathology,
19, 195–204. https://doi.org/10.1080/17549507.2016.1193899
Mathworks. (2015). MATLAB R2015a [Computer software].
Natick, MA: Author.
Milenkovic, P. (2001). TF32 [Computer software]. Madison, WI:
Author.
Neel, A. T., & Palmer, P. M. (2012). Is tongue strength an im-
portant influence on rate of articulation in diadochokinetic
and reading tasks? Journal of Speech, Language, and Hearing
Research, 55(1), 235–246. https://doi.org/10.1044/1092-4388
(2011/10-0258)
R Core Team. (2014). R: A language and environment for statisti-
cal computing. Available from https://www.r-project.org/
Rong, P., Yunusova, Y., Wang, J., Zinman, L., Pattee, G. L.,
Berry, J. D., . . . Green, J. R. (2016). Predicting speech intelli-
gibility decline in amyotrophic lateral sclerosis based on the
deterioration of individual speech subsystems. PLoS One,
11(5), e0154971.
Shellikeri, S., Green, J. R., Kulkarni, M., Rong, P., Martino, R.,
Zinman, L., & Yunusova, Y. (2016). Speech movement mea-
sures as markers of bulbar disease in amyotrophic lateral scle-
rosis. Journal of Speech, Language, and Hearing Research,
59(5), 887–899.
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/13/2021, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Tjaden, K., Sussman, J. E., & Wilding, G. E. (2014). Impact of
clear, loud, and slow speech on scaled intelligibility and speech
severity in Parkinson’s disease and multiple sclerosis. Journal
of Speech, Language, and Hearing Research, 57(3), 779–792.
https://doi.org/10.1044/2014_JSLHR-S-12-0372
Tsao, Y.-C., & Weismer, G. (1997). Interspeaker variation in habit-
ual speaking rate: Evidence for a neuromuscular component.
Journal of Speech and Hearing Research, 40(4), 858–866.
Tsao, Y.-C., Weismer, G., & Iqbal, K. (2006). The effect of inter-
talker speech rate variation on acoustic vowel space. The Jour-
nal of the Acoustical Society of America, 119(2), 1074–1082.
Weismer, G. (2013). Speech science: Technique, concept, theory.
Perspectives on Speech Science and Orofacial Disorders, 23,
6–17.
Weismer, G., Jeng, J.-Y., Laures, J. S., Kent, R. D., & Kent, J. F.
(2001). Acoustic and intelligibility characteristics of sentence
production in neurogenic speech disorders. Folia Phoniatrica
et Logopaedica, 53(1), 1–18.
Weismer, G., Martin, R., Kent, R. D., & Kent, J. F. (1992). For-
mant trajectory characteristics of males with amyotrophic lat-
eral sclerosis. The Journal of the Acoustical Society of America,
91(2), 1085–1098.
Weismer, G., Yunusova, Y., & Bunton, K. (2012). Measures to
evaluate the effects of DBS on speech production. Journal of
Neurolinguistics, 25(2), 74–94. https://doi.org/10.1016/j.jneuroling.
2011.08.006
Yorkston, K. M., Beukelman, D., Hakel, M., & Dorsey, M. (1996).
Speech intelligibility test for windows. Lincoln, NE: Com-
munication Disorders Software.
Yorkston, K. M., Beukelman, D. R., & Bell, K. R. (1999). Man-
agement of motor speech disorders in children and adults.
Austin, TX: Pro-Ed.
Yorkston, K. M., Strand, E., Miller, R., Hillel, A., & Smith, K.
(1993). Speech deterioration in amyotrophic lateral sclerosis:
Implications for the timing of intervention. Journal of Medical
Speech-Language Pathology, 1(1), 35–46.
Yunusova, Y., Green, J. R., Lindstrom, M. J., Ball, L. J., Pattee,
G. L., & Zinman, L. (2010). Kinematics of disease progression
in bulbar ALS. Journal of Communication Disorders, 43(1),
6–20. https://doi.org/10.1016/j.jcomdis.2009.07.003
Yunusova, Y., Weismer, G., Westbury, J. R., & Lindstrom, M. J.
(2008). Articulatory movements during vowels in speakers
with dysarthria and healthy controls. Journal of Speech, Lan-
guage, and Hearing Research, 51(3), 596–611. https://doi.org/
10.1044/1092-4388(2008/043)
Lee & Bell: Articulatory Range of Movement in ALS 1009