Logopedics Phoniatrics Vocology

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ilog20

Speech intelligibility of Parkinson’s disease

patients evaluated by different groups of
healthcare professionals and naïve listeners

Joana Carvalho , Rita Cardoso , Isabel Guimarães & Joaquim J. Ferreira

To cite this article: Joana Carvalho , Rita Cardoso , Isabel Guimarães & Joaquim J. Ferreira
(2020): Speech intelligibility of Parkinson’s disease patients evaluated by different groups
of healthcare professionals and naïve listeners, Logopedics Phoniatrics Vocology, DOI:
10.1080/14015439.2020.1785546

To link to this article: https://doi.org/10.1080/14015439.2020.1785546

Published online: 07 Jul 2020.

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LOGOPEDICS PHONIATRICS VOCOLOGY
https://doi.org/10.1080/14015439.2020.1785546

ORIGINAL ARTICLE

Speech intelligibility of Parkinson’s disease patients evaluated by different

groups of healthcare professionals and naïve listeners
Joana Carvalhoa,b, Rita Cardosoa,b, Isabel Guimar~aesc and Joaquim J. Ferreiraa,b
a
Clinical Pharmacological Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; bCampus
Neurologico Senior, Torres Vedras, Portugal; cDepartment of Speech Therapy, Escola Superior de Saude de Alcoit~ao, Estoril, Portugal

ABSTRACT ARTICLE HISTORY

Introduction: Speech intelligibility, how well a listener comprehends the speaker’s message, is related Received 1 April 2020
to the listener’ expertise and type of the message conveyed. There is no evidence about speech intelli- Revised 8 June 2020
gibility in different groups of healthcare professionals and naïve listeners. Accepted 15 June 2020
Objectives: This study is the first to understand if there were differences in the speech intelligibility of
KEYWORDS
Parkinson’s Disease (PD) patients by different experienced and naïve listeners, according to the speech Dysarthria; intelligibility;
stimuli and dysarthria severity. audio-perceptive analysis;
Materials and methods: Randomly digitised audio-files (50 words and 50 sentences) of 10 PD Parkinson’s disease
patients, one without dysarthria and 9 with different dysarthria severities (3 each: mild, moderate and
severe dysarthria), were collected from a database of 60 PD patients’ audio-files. A jury panel was
formed by five different listeners groups including 10 speech and language therapists, 10 neurologists,
10 PD relatives, 12 PD patients, and 10 people from the general population. The jury panel transcribed
single words and sentences from the audio recordings, the percentage correctly understood was cal-
culated and the results were compared between the groups.
Results: Multiple comparisons showed significant speech intelligibility differences between healthcare
professionals and naïve listerners in words (highest effect size, g2 ¼ 0.7) and sentences (the highest
effect size: g2 ¼ 0.6). Pairwise comparisons revealed that those significant differences were specifically
in words with moderate and severe dysarthria and sentences with all severity levels of dysarthria.
Conclusion: The groups of healthcare professionals who work with dysarthria are more likely to
understand the PD patients’ speech than the groups of naïve listeners.

Introduction judging PD speech intelligibility, in a reliable manner [8] while

Speech intelligibility, how well a speaker’s acoustic signal
can be accurately recovered by a listener [1,2] is commonly
used as a functional index of the communicative perform-
ance on Parkinson’s disease (PD) patients with hypokinetic
dysarthria. Ninety percent of Parkinson’s disease (PD)
patients present reduced speech intelligibility that is
expected to decline with disease progression [2,3]. Clearly,
low levels of intelligibility may limit substantially the PD
patients’ independence affecting their participation at the
society level and thus their quality of life [2].
Speech intelligibility is typically measured by having lis-
teners orthographically transcribe words or sentences that
the speaker had read and a score is calculated dividing the
number of words or sentences understood and the total
number of words or sentences spoken [4,5].
Prior research suggests that speech intelligibility may be
affected by many variables like:
(i) Listener’s experience and training [2,6,7]. There is con-
flicting evidence regarding the role of listener experience (naïve
versus expert) in the assessment of dysarthric speech [4]. Some
researchers demonstrated that naïve listeners are capable of
others found no significant difference in speech intelligibility
between experienced and in experienced listeners for dysarthric
speech [4]. Kreiman et al. [5] state that clinical training and
experience might influence speech perception. In fact, experi-
enced listeners (78%) had higher speech intelligibility than
naïve listeners (50%) in adults with dysarthria secondary to
cerebral palsy [9]. Platt et al. [9] showed that naïve listeners
without formal training do not have specific internal standards
for judging pathological qualities.
While previous work has compared speech intelligibility
by experienced listeners versus naïve listeners [5,8] to the
authors best of knowledge, no previous investigation has
specifically addressed the differences between groups of pro-
fessional experienced listeners. Moreover, studies mention-
ing naïve listeners are mainly with the general population
[10–12] and few with PD patients [13–15] and PD rela-
tives [12].
(ii) Listener’s familiarity. Results of studies examining
familiarity with the content of the spoken message have
been equivocal likely because of methodological differences.
Tjaden and Liss [14] showed that SLT undergraduate

CONTACT Joana Carvalho joana.margarida.cr@gmail.com Clinical Pharmacological Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of
Lisbon; Campus Neurologico Senior, Torres Vedras, Lisbon, Portugal
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 J. CARVALHO ET AL.
students previously familiarized with dysarthric speech
obtained significantly better speech intelligibility scores than
SLT undergraduate students without familiarity with dys-
arthric speech. In contrast, Walshe et al. [13–15] found non-
significant differences in speech intelligibility across three
groups of listeners familiarized with the speech stimuli used
in the research. Even so, the adult speakers with dysarthria
presented the lowest listeners’ intelligibility ratings.
(iii) Type of speech stimuli (the speech content or the
degree of dysarthria). Speech intelligibility is driven by mul-
tiple sources including voice (e.g. pitch, timbre, and timing)
and linguistic (e.g. lexicality, phonological and syntactic)
cues. Semantic predictability dramatically affects a listener’s
ability to understand speech, with sentences more predict-
able than single words resulting in higher intelligibility
scores [16]. This evidence is confirmed both for normal and
dysarthric speech [6,17–19]. When considering the disor-
dered speech research shows that the severity grade corre-
lates with intelligibility rating in that higher intelligibility
scores correspond to lower grade dysarthria [20]. Also,
some authors stress the benefit of knowing the syntax over
the semantic cue provided, particularly for mild dysarthria
[10]. Different listeners’ judgments of normal and nearly
normal voices are comparable possibly due to the similar
exposure to what constitutes a normal voice [5,14].
However, for the intermediate grade dysphonia even experi-
enced raters are subject to great variability [10].
(iv) Listeners biases (e.g. fatigue, hearing sensitivity,
attention lapses) are considered random effects that can
cause a drift in perceptual judgments [10]. Wild et al. [21]
unequivocally demonstrated that clear speech can be proc-
essed even with low attentional level but degraded speech is
processed depending on the listener’s state of attentiveness.
In this study the primary aim was on the listeners and
their capacity to understand PD patients’ speech. The main
hypothesis was that professional experienced listeners
(Neurologists and Speech and Language Therapists (SLTs))
would have different hit percentages in speech intelligibility
than naïve listeners (PD patients, PD relatives, and General
Population, GP). Within the naïve speakers those with PD
speech familiarity are also expected to have different hit per-
centages than those without PD speech familiarity. If intelligi-
bility varies within different groups of listeners it is
important to take all of them into account when intelligibility
is being assessed. Another aim is to understand the dysarthria
severity effect in speech intelligibility. Given research suggest-
ing that speech dimensions deteriorate in the course of the
PD disease it was hypothesized that severe dysarthria would
yield worst speech intelligibility than mild and moderate dys-
arthria severities. Understanding the speech intelligibility in
the different levels of dysarthria may provide specific thera-
peutic clues to improve the PD patients’ communication.
Materials and methods
A cross-sectional study was approved by an ethical commit-
tee and the study was conducted in accordance with the
Declaration of Helsinki.
Listeners –jury panel
Jury panel
A jury panel formed by healthcare professionals (10 speech
and language therapists and 10 neurologists) and naïve lis-
teners (12 PD patients, 10 PD relatives, and 10 people from
the general population) was organized. The elements of the
jury panel had to fulfill the following criteria: (i) All listen-
ers had to report normal hearing abilities and to be blind to
any speaker or speech stimuli list variables; (ii) Health care
professionals had to report working experience with adults’
dysarthria; (iii) The PD relatives had to report daily contact
with PD patient; (iv) The general population (GP) had to
report no daily contact with PD patients, family or acquain-
tances with disease; (v) The PD patients had to be without
diagnosed cognitive deficit that prevented collaboration in
the study and without having undergone to deep brain
stimulation.
Materials
Ten digitized audio files randomly selected from 10 male
PD patients reading single words and sentences were drawn
from a database of 60 PD patients’ audio-files without dys-
arthria and with mild to severe dysarthria. Only men were
recruited since there are differences between sexes in terms
of speech characteristics which could bias the results. The
PD patients were native Portuguese speakers, who had a
mean age of 72.2 years ± 7.9 SD and 8.8 years of education
± 5.8 SD. All presented a medical diagnosis of idiopathic
PD according to the UK Parkinson’s Disease Brain Bank
Criteria [22]. Time from diagnosis ranged from 4 to 19
years and based on the Hoehn and Yahra disease stage
between 1 and 5. The PD disability and impairment was
discrete for the PD patient without hypokinetic dysarthria
(MDS-UPDRS overall score equal to 113) and slight to
moderate for the nine PD patients with hypokinetic dysarth-
ria (MDS-UPDRS overall score between 148 and 225). All
patients were taking medication and were assessed in the
“ON” condition.
The dysarthria diagnosis and level of severity was per-
formed by an SLT expert in the assessment and treatment
of acquired sensorimotor speech disorders, using the
Frenchay Dysarthria Assessment – 2nd edition (FDA-2)
European Portuguese version protocol [23] and a Clinical
Global Impression (CGI) scale. Data had been recorded in a
quiet room with professional speech recording equipment.
Two other SLTs experienced in PD perform an audio-per-
ceptive analysis of the recording files also using CGI. The
patients included in this study were those were 100% agree-
ment between the raters was achieved.
The digitised audio-files selected from each patient
include five single words and five sentences chosen from a
set of 12 words and sentences read by each patient. Some of
the files presented a spurious noise that was impossible to
filter. To harmonise the quantity of stimuli between PD
patients and levels of dysarthria severity levels it was only
used 10 from each. It is worth mentioning that the

application of FDA-2 EP version intelligibility task implies
the performance of 12 words and sentences randomly
chosen from a set of 109 words and 60 sentences [23].
These tasks include a group of samples with strong correla-
tions in terms of distribution of frequency of phonemes,
word length, and type of syllabic structure involved. A total
stimulus of 50 different words (5 without dysarthria and 15
for each dysarthria severity level) and 50 different sentences
(5 without dysarthria and 15 for each dysarthria severity
level) were gathered at the end.
Procedures
For this study, the peak amplitude of the selected audio
stimuli was normalized with a software with the initial
default setting is 1 dB. Reliability of the dysarthria severity
was reanalyzed by two other SLTs, also with expertise in
PD, by means of an audio-perceptive analysis of the record-
ing files.
The jury panel was informed about the purpose and pro-
ceedings of this study by reading an information sheet and
if the participant wished to continue an informed consent
form was signed. The audio-files – single words and senten-
ces – were presented separately, once only, using stereo
headphones connected to a laptop at 50% volume level.
Between each word there was a four second interval and
between each sentence a seven second interval. The panel
members were instructed to write down what they heard.
All listeners were blind to the background information of
the speakers and to the other listeners ratings.
Statistical analysis
The transcribed single words and sentences were considered
“correct” if there was a perfect match between all words and
phonemes spoken and written by the jury, or “incorrect” if
there was not. The primary outcome was the total words
correctly understood and it was calculated and presented as
a hit percentage, mean values, and standard deviation 95%
confidence interval (CI) per group, and the hit percentage
per level of dysarthria.
Normal distribution was investigated with the Shapiro
Wilk test and homogeneity of the variances with Levene’s
test. Since the homogeneity of the variance was not verified,
a non-parametric test was chosen to compare results
between the groups – a Kruskall–Wallis test (adjusted for
tied ranks) – and follow-up tests were conducted to evaluate
pairwise differences among the five groups and the effect
size for pairwise comparisons was presented with statistically
Table 1. Demographic data for the jury panel.
N Age mean ± SD (range) Gender (%) F (female) j M (male)
PD patients 12 65.6 ± 7.2 (55–76) F ¼ 33.3% j M ¼ 66.7%
PD Relatives 10 65.0 ± 6.0 (56–75) F ¼ 100% j M ¼ 0%
GP 10 62.6 ± 6.2 (57–76) F ¼ 40% j M ¼ 60%
SLTs 10 40.7 ± 12.5 (25–57) F ¼ 90% j M ¼ 10%
Neurologists 10 43.9 ± 7.4 (34–56) F ¼ 40% j M ¼ 60%
LOGOPEDICS PHONIATRICS VOCOLOGY 3
significant values. The same methodology was applied to
sentences correctly understood.
The inter-rater reliability was calculated by means of per-
cent agreement. Results demonstrate an almost perfect
agreement between the jury panel in each group in terms of
intelligibility of single words (all groups with 0.9 percent
agreement) and sentences (GP and PD patients with 0.8
percent agreement and healthcare professionals and PD rela-
tives with 0.9).
All descriptive and inferential results were obtained using
SPSSV Software, version 20.0 (SPSS, Inc., Chicago, IL) and
R
p-values less than .05 were considered significant.
Results
Jury panel
Fifty-two listeners aged 25–76 years participated in the
study. The healthcare professionals are significantly younger
(p ¼ .001) than the naïve listeners. Within the healthcare
professionals and the naïve listeners groups the mean age
was not significantly different (p > .05) (Table 1). The
majority of the listeners were females except in the PD
patients’ listeners who were mainly men (Table 1). The
healthcare professionals (all with higher education) have a
similar level of education as half of the PD patients and a
higher level of education than the majority of the other
naïve jury panel (PD relatives and GP). Globally, GP is the
naïve listeners with the lower level of education. The SLTs
reported a mean of working experience of 17.9 years ±3.9
with adults with dysarthria other than PD patients. The
Neurologists have a mean of working experience of
16.4 years ±3.9 of working with movement disorders, par-
ticularly with PD.
Professional experienced versus naï ve listeners
Descriptive statistics revealed differences in the hit percent-
age and mean number of words correctly understood
between groups. In ascending order PD patients < GP < PD
relatives < SLTs < Neurologists (Table 2).
Statistical analysis indicate that there are significant over-
all differences between the medians of the total words cor-
rectly annotated by the five groups v2 (4, N ¼ 52) ¼ 19.0,
p ¼ .001with a mean rank of 18.7 for the GP, 33.2 for SLTs,
41.7 for Neurologists, 22.0 for PD relatives and 18.7 for PD
patients. The effect size was not high, g2¼ v2/N  1,
g2¼0.4. Because the overall test is significant, pairwise com-
parisons among the five groups were completed and showed
significant differences only between: (i) the healthcare
Education, N (%)
Elementary, <4 years Secondary, 5–11 years Higher, >12 years
2 (16.7%) 4 (33.3%) 6 (50%)
2 (20%) 4 (40%) 4 (40%)
5 (50%) 5 (50%) 0
0 0 10 (100%)
0 0 10 (100%)
4 J. CARVALHO ET AL.

Table 2. Listeners’ hit percentage (%). Table 3. Speech intelligibility (%) according to dysarthria severity.
Words Sentences Dysarthria
Listeners % M ± SD 95% CI % M ± SD 95% CI Normal speech Mild Moderate Severe
PD patients 56.2 28.1 ± 5.7 24.5–31.7 61.2 30.6 ± 4.8 27.6–33.6 PD patients Words 93.3 57.8 71.1 27.2
PD relatives 60.6 30.3 ± 4.5 27.1–33.5 66.4 33.2 ± 4.0 30.3–36.1 Sentences 81.7 71.1 68.3 37.2
GP 60.2 30.1 ± 2.3 28.5–31.7 67.8 33.9 ± 4.0 31.1–36.8 PD relatives Words 98 68.7 75.3 26.7
SLTs 66.8 33.4 ± 2.4 31.7–35.1 73.0 36.5 ± 2.7 34.6–38.4 Sentences 74 73.3 78 45.3
Neurologists 70.4 35.2 ± 1.9 33.8–36.6 75.0 37.5 ± 2.0 36.1–38.9 GP Words 98 64 72.7 30.7
M ± SD: mean ± standard deviation; CI: confidence interval. Sentences 82 76 79.3 43.3
SLT Words 100 77.3 83.3 28.7
Sentences 84 84 82.7 48.7
professionals (SLTs and Neurologists) and the GP (v2 (1, Neurologists Words 98 86 87.3 28.0
Sentences 92 82 81.3 56
N ¼ 20) ¼ 6.6, p ¼ .01 g2¼0.3 and v2 (1, N ¼ 20) ¼ 12.9, p
¼ .001g2¼0.7 respectively); (ii) Neurologists and PD rela-
tives (v2 (1, N ¼ 20) ¼ 8.7, p ¼ .001 g2¼0.5) and PD
patients (v2 (1, N ¼ 22) ¼ 9.0, p ¼ .001g2¼0.4). than sentences for the control speech stimuli, without dys-
A specific analysis within the naïve jury groups matched arthria; (ii) equal in words and sentences for the moderate
by educational level showed non-significant results between dysarthria; (iii) lower in words than sentences for mild and
the groups at the elementary level of education (v2 (3, severe dysarthria.
N ¼ 9) ¼ 10.350, p ¼ .410) and at the secondary level of Comparing the percentage magnitude between normal
education (v2 (3, N ¼ 12) ¼ 18.200, p ¼ .312) for words. speech intelligibility and: (i) severe dysarthria it reduced
Table 2 shows that speech intelligibility for sentences is 67.3% in words and 36.9% in sentences; (ii) moderate dys-
slightly different between groups. In ascending order: PD arthria it reduced 19.4% in words and 5.1% in sentences;
patients < PD relatives < GP < SLTs < Neurologists. Statistical (iii) mild dysarthria it reduced 30.4% in words and 5.6% in
analysis indicate that there are significant overall differences sentences (Table 5).
between the medians of the total sentences correctly anno-
tated by the five groups v2 (4, N ¼ 52) ¼ 18.0, p ¼ .001with a
mean rank of 26.0 for GP, 32.4 for SLTs, 39.9 for Discussion
Neurologists, 22.4 for PD relatives, and 14.3 for PD patients. Professional experienced versus naive listeners
The effect size was not high, g2¼ v2/N  1, g2 ¼ 0.4. Because
the overall test is significant, pairwise comparisons among The current findings show a significant difference between
the five groups were completed and significant differences professional experienced listeners (Neurologists and SLTs) and
were found between: (i) SLTs and PD patients (v2 (1, naïve listeners in speech intelligibility. These results lend sup-
N ¼ 22) ¼ 7.8, p ¼ .01 g2¼0.4); and (ii) Neurologists and port to the published literature that refers professional experi-
PD patients (v2(1, N ¼ 22) ¼ 13.318, p ¼ .001 g2¼0.6) and enced listeners effects in the intelligibility of speech [9,11].
PD relatives (v2 (1, N ¼ 20) ¼ 7.612, p ¼ .01 g2¼0.6). Although not significant, within the professionals experienced
Within the naïve jury groups matched by educational listeners, Neurologists had slightly higher intelligibility hit per-
level showed non-significant results for the sentences centages than SLTs. Considering that both have professional
between the groups at the elementary level of education (v2 experience in adults’ dysarthria a possible explanation for this
(3, N ¼ 9) ¼ 18.0, p ¼ .324) and at the secondary level of difference is the Neurologists familiarization with PD patients
education (v2 (3, N ¼ 12) ¼ 13.180, p ¼ .518). for more than five years against no experience with PD
Overall healthcare professionals (SLTs and Neurologists) patients for the SLTs. Moreover, the Neurologists, with expert-
had the highest hit percentage for all speech stimuli while ise in PD, in this study, seem to be highly sensitive to PD
PD patients had the lowest (Table 3). speech (words and sentences) and to corroborate this is the
The statistical analysis between the medians of the total significant intelligibility difference they make from the PD
words according to dysarthria severity correctly annotated patients and PD relatives listeners. Conversely, SLTs without
by the five groups showed significant differences only for experience in PD only distinguish themselves from GP (in the
the words with moderate (v2 (4, N ¼ 52) ¼ 10.1, p ¼ .039) words stimuli) and PD patients (in the sentences stimuli).
and severe (v2 (4, N ¼ 52) ¼ 17.1, p ¼ .002) dysarthria and These innovative results seem to indicate the need for expertise
for the sentences with mild (v2 (4, N ¼ 52) ¼ 11.733, and experience not only in adults’ dysarthria but also in the
p ¼ .019), moderate (v2 (4, N ¼ 52) ¼ 19.443, p ¼ .001) and underlying condition, namely PD [9,11].
severe (v2 (4, N ¼ 52) ¼ 17.254, p ¼ .002) dysarthria. One striking finding was the homogeneity of the ratings
Table 4 reveals the dysarthria severity levels significant across the naive listeners rather than an expected difference
differences between health care professionals and the naïve between familiarized listeners as the PD patients and PD
listeners for moderate and severe dysarthria. relatives and nonfamiliarized listeners as the GP group.
These results stand in contrast with those reported by a
number of authors who argued that prior familiarization
Speech stimuli effect
with a specific speaker led to increased intelligibility scores
Table 5 summarizes all the hit percentage of intelligibility [13,14]. However, the PD patients and PD relatives groups,
for the speech stimuli showing that it is: (i) higher in words in this study, were not familiar with the patients’ recorded
 LOGOPEDICS PHONIATRICS VOCOLOGY 5

Table 4. Pairwise comparisons according to dysarthria and type of listener.

Speech stimuli Listeners Mann–Whitney p Value
Words with moderate dysarthria SLT versus PD U ¼ 29.500 .041
Neurologists versus PD U ¼ 17.000 .004
Words with severe dysarthria SLT versus PD U ¼ 20.500 .025
SLT versus GP U ¼ 22.000 .033
Neurologists versus PD relatives U ¼ 9.000 .002
Neurologists versus GP U ¼ 8.500 .002
Sentences with mild dysarthria SLT versus PD U ¼ 23.000 .013
Neurologists versus PD U ¼ 15.000 .003
Sentences with moderate dysarthria SLT versus PD U ¼ 11.000 .001
Neurologists versus PD U ¼ 10.000 .001
Sentences with severe dysarthria SLT versus PD U ¼ 26.000 .020
Neurologists versus PD U ¼ 11.500 .001
Neurologists versus GP U ¼ 13.500 .005
Neurologists versus PD relatives U ¼ 19.000 .017

Table 5. Percentage of words and sentences correctly transcribed per level
of dysarthria.
Words Sentences
Dysarthria Dysarthria
Without Mild Moderate Severe Without Mild Moderate
97.7% 67.3% 78.3% 30.4% 82.7% 77.1% 77.6%
speech. Unfortunately the body of research with naïve lis-
teners like the ones in this study was not found in the lit-
erature therefore comparisons are not possible.
Several hypotheses can be considered to explain these
results. First, it may be possible that PD relatives, in this
study, had a reduced exposure to the speech dimensions pre-
sent in the stimuli considering that PD speech dysarthria is
highly variable among speakers. Second, it is possible that PD
relatives are used to contextual intelligibility (intelligibility
associated with visual cues, e.g. physical context, facial expres-
sion, body language and gestures) and not only to isolated
acoustic speech. In fact, research shows that visual informa-
tion gives the listener additional cues to decode speech [6].
Third, although no statistically significant difference exists
within the naïve listeners groups it should be noted that, in
this study, PD patients’ speech intelligibility hit percentage is
the lowest. The published literature states that people with
dysarthria may perceive their own speech differently to those
without dysarthria [16] and suggests that PD patients lack
insight into their speech difficulties [17]. However, the aim of
this study was about PD patients’ perceptions of others’ dys-
arthric speech without visual aspects of communication [1].
Finally, it can be speculated if this results from random
effects such as listening fatigue and attention lapses have
interfered with speech intelligibility [10].
Speech intelligibility is a key component in human com-
munication and the results of this study point out to need
for specific training and experience of healthcare professio-
nals. Also important is the naive listeners’ education to
endow them with knowledge, strategies, and tools so that
the PD patient can be more easily understood.
Speech stimuli effect
One expected finding was the type of speech stimuli, words
versus sentences, effect in intelligibility. In this study, globally,
higher values were obtained in the intelligibility of sentences
than words for all dysarthria severities. Evidence highlights
that a sentence, with the presence of context provided by the
semantics improves the listeners’ accuracy than a single word
[24,25]. Nevertheless, for the control speech stimuli, without
Severe dysarthria, sentences seemed to be more difficult to understand
45.8%
than words and it seems reasonable to speculate if: (i) the talk-
ers’ speech rate (e.g. accelerated speech) that reduces articula-
tory accuracy and consequently the speech intelligibility; (ii)
the listeners’ sensitivity to normal age-related changes in
speech, perhaps especially changes related to voice or prosody
as stated in a study from Sussman and Tjaden [26]; (iii) the
normal speech is under represented (one) sample against three
for each dysarthria severity.
Listeners recognized better the normal speech (between
83 and 98%) than the disordered dysarthric speech (between
30 and 78%) which is in line with the results from other
study [12]. The severe dysarthria speech stimuli are the
most difficult to understand with a declination in intelligi-
bility, when compared to the normal speech, higher than
67% in words and more than 37% in sentences. This result
seems obvious considering the expected speech decline with
disease progression and therefore an understanding higher
negative impact [2,3]. Another unexpected result is that
words with mild dysarthria seem more difficult to under-
stand than those with moderate dysarthria (10% more diffi-
cult) and sentences are similarly understood (5% worst for
moderate dysarthria). It is possible that the results obtained
are related to (i) the reference levels of mild and moderate
dysarthria used to categorize the speech stimuli. Dysarthria
severity categorization depends on the presence of segmental
and supra segmental degradation patterns that impact the
integrity of the speech signal. This categorization was per-
formed by SLTs with expertise and experience in PD in the
presence of the PD patients. So, it is possible that SLT esti-
mates may be biased by the knowledge of the speakers’
background and/or familiarity with the FDA-2 intelligibility
tasks content and/or by the presence of the speaker at the
assessment data (audiovisual intelligibility)[13–15]; (ii) the
transcription system used, in this study, may not be sensi-
tive to measure small intelligibility differences [13–15].
Considering the role and importance of intelligibility as
an outcome in SLT field, more research is need to deter-
mine the degree of impairment and how to monitor the
changes of speech intelligibility.
6 J. CARVALHO ET AL.
Limitations
Although the present results are innovative for the know-
ledge of PD patients’ speech by different groups of listeners
and show some promising trends there are certain limita-
tions that must be mentioned. First, the cross-sectional
nature of this study and the small-scale sample of listeners
limits the generalizability of the results. Nevertheless, this
study provided innovative data by using five different
groups of listeners. Second, listeners’ hearing accuracy was
based on self-report, therefore comparable hearing accuracy
among and between groups cannot be guaranteed. Third,
the significantly lower level of education in the GP group
compared to the other naïve listeners groups might have
been a major limitation to the ability to transcript words
and sentences correctly. In Portugal, 52.8% of individuals
aged 65 years or older have only a primary school level of
education [27]. Admittedly, less educated individuals have
lower frequency of reading and writing habits. However,
this conjecture is beyond the scope of this study. Fourth,
the type of error of the sentence (e.g. phonetical or lexical)
was not taken into account and if it had changed the mean-
ing of the sentence. Therefore, it is not possible to inference
if the type of error influenced the intelligibility rating of all
or a particularly group of listeners although it was not the
purpose of this study. Moreover, the aim was to use the real
PD speech signal. Fourth, the stimuli audio-data were
selected from PD patients in ON state.
Suggestions for future research
Future research should increase the strength of these results
and seek improvement directed towards: (i) enhancing formal
examination through a hearing screening prior to presenting
speech stimuli. Prevalence of age-related hearing loss, in the
United States, is approximately one in three people age 65–74
and nearly one in two people age 75[28]; (ii) distinguish
between intelligibility (acoustic signal only) and comprehensi-
bility (visual and acoustic information) data from PD rela-
tives and GP listeners can be a useful index to better predict
how PD patients are perceived by naïve listeners [17]; (iii)
identifying speech intelligibility analysis with ON and OF
state PD patients, and also (iv) determining speech intelligi-
bility in dysarthria secondary to Multisystemic Atrophy,
Supranuclear Palsy and cerebellar ataxia.
Acknowledgments
The authors gratefully acknowledge all participants for their voluntary
collaboration in this study.
Disclosure statement
This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors. None of the
authors have any conflicts of interest or financial disclosures to report.
Notes on contributors
Joana Carvalho Degree in Speech Therapy from the School of Health
of the University of Aveiro. Master in neuroscience from the Faculty
of Medicine of the University of Lisbon. Post-graduated in oropharyn-
geal dysphagia by the Epap Institute (I.EPAP). Working as a speech
therapist at Campus Neurologico Senior since 2014. Researcher at the
Instituto de Medicina Molecular, dedicated to the study of speech and
swallowing disorders in movement disorders. Involvement in financed
project in the field of the article: FraLusoPark-Dysarthria in Parkinson
Disease project coordinated by Serge Pinto (Laboratoire Parole et
Langage, Universite Aix-Marselle/CNRS) and Joaquim Ferreira
(Institute of Molecular Medicine, Faculty of Medicine of Lisbon)
(http://dx.doi.org/10.1136/bmjopen-2016-012885).
Rita Cardoso Degree in Speech Therapy from the School of Health of
the University of Aveiro. Master in neuroscience from the Faculty of
Medicine of the University of Lisbon. Post-graduated in oropharyngeal
dysphagia by the Epap Institute (I.EPAP). Coordinator of the speech
therapist therapy service at the Senior Neurological Campus in Torres
Vedras, where she works exclusively with neurological pathology.
Lecturer of Speech Therapy at the Alcoit~ao Health School of Sciences.
Member of the Portuguese Society for Movement Diseases (SPDMOV)
and the Portuguese Society for Speech Therapy (SPTF). Researcher at
the Instituto de Medicina Molecular, dedicated to the study of speech
and swallowing disorders in movement disorders. Involvement in
financed project in the field of the article: FraLusoPark-Dysarthria in
Parkinson Disease.
Isabel Guimar~ aes Bachelor of Speech Therapy; Post-graduated in
Lecturing and Administration from Alcoit~ao Health School of Sciences;
PhD in Experimental Phonetics - University College London, currently
Professor at the Alcoit~ao Health School of Sciences, Coordinator of the
Master in Speech Therapy (specialization in Orofacial Motricity and
Swallowing); Senior researcher at the Unit of Clinical Pharmacology
and Therapeutics - Institute of Molecular Medicine - University of
Lisbon; Founder and former editor-in-chief of the Portuguese Journal
of Speech Therapy; Currently scientific Vice-President of the
Portuguese Society of Speech Therapists; Involvement in financed pro-
ject in the field of the article: FraLusoPark-Dysarthria in
Parkinson Disease.
Joaquim J. Ferreira Neurologist, having completed his medical training
and subsequent PhD in Neurology at the Faculty of Medicine of the
University of Lisbon, currently Professor of Neurology and Clinical
Pharmacology and Director of the Laboratory of Clinical
Pharmacology and Therapeutics at the Faculty of Medicine of the
University of Lisbon, director of a Research Group at the Institute of
Molecular Medicine and Clinical Director of the CNS-Campus
Neurol
ogico Senior, co-director of the Movement Diseases Panel of the
European Academy of Neurology and former President of the
European Section of the International Society for Parkinson’s Disease
and other Diseases of the Movement.
ORCID
Joaquim J. Ferreira http://orcid.org/0000-0003-3950-5113
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