Amyotrophic lateral sclerosis: Toward

evidence-based management of
dysarthria
Kathryn M. Yorkston, PhD, BC-NCD
Laura Ball, PhD
David R. Beukelman, PhD
Pamela Mathy, PhD

Website
http://www.ticeinfo.com
http://aac.unl.edu
2

Amyotrophic Lateral Sclerosis

(ALS)
Degenerative motor neuron disease
Muscle atrophy and spasticity
In the limbs and bulbar muscles
Dysarthria and dysphagia are common
Decisions for SLP re: types & timing of:

speech intervention
AAC intervention
3

Overview
An introduction to evidence-based decision making
Yorkston - University of Washington
Question 1: How can early bulbar symptoms be
identified?
Ball - University of Nebraska, Omaha
Question 2: What techniques are appropriate for
maintenance of natural speech in progressive dysarthria?
Beukelman, University of Nebraska, Lincoln
Question 3: Are AAC techniques effective in maintaining
communication in ALS?
Mathy, Arizona State University
4

Introduction of Terms

Evidence-based practice

Practice guidelines

Staging of intervention

Toward Evidence-Based Practice

Medical students do the wrong things in a

clinical setting not because of a deficiency
in knowledge, but because they dont make
good decisions. They know a lot, but they
dont think systematically.
(Arthur Elstein, Ph.D, University of Illinois,
presenting a lecture at University of Washington,
April 27, 1999).
6

Evidence-Based Practice

. . is a commitment to a constant
reexamination of practices through research
and outcomes analyses.
- Enhancing our knowledge-base
- Enhancing our decision making
[Sackett et al., (1997)]
7

Evidence-Based Practice

. . an approach to decision making in

which the clinician uses the best evidence
available, in consultation with the patient,
to decide upon the option which suits that
patient best.

[Muir Gray, 1997]

8

Evidence-based practice is of
interest to:
Practitioners
Policymakers
Payers
Purchasers
Patients
Public

Definition: Practice Guidelines

Clinical practice guidelines are explicit

descriptions of how patients should be
evaluated and treated. The explicit purpose
of guidelines is to improve the quality of
care and to assure it by reducing variation
in care provided.
- review

of evidence
- consensus of experts
10

Practice Guidelines
Examples from ALS

breaking the news to patients and

families,

nutrition and PEG placements,

respiratory insufficiency and mechanical

ventilation,

management of emotional lability,

and palliative care.

American Academy of Neurology
Miller et al, 1999

11

ANCDS - Practice Guidelines

Velopharyngeal
Management
Behavioral Tx of
Respiration/Phonation
Surgical/Pharm. Tx of
Phonation
Speech Supplementation
Tx of Speech Rate &
Naturalness

Technical Report due

Nov. 2000
Ready for expert review
Jan. 2001
Ready for expert review
Jan. 2001
Ready for expert review
Dec. 2000
To be drafted, 2001
12

Definition: Staging
.

. . the sequencing of management so

that current problems are addressed
and future problems anticipated.

13

ALS: Stage 1
No Detectable Speech Disorder
. . Diagnosis has been made, but often
speakers do not yet exhibit speech
symptoms in those with spinal
presentation.

14

ALS: Stage 2
Obvious Speech Disorder with
Intelligible Speech
. . both the speaker and listener notice
changes in speech - speakers may perceive
extra effort needed for speech.

15

ALS: Stage 3
Reduction in Speech Intelligibility
. . . changes in speaking rate, articulation, and
resonance are all evident.

16

ALS: Stage 4
Natural Speech - Supplemented
. . . natural speech is no longer a
functional means of communication in
all situations.

17

ALS: Stage 5
No Functional Speech
. . . speakers with advance bulbar ALS
have lost functional speech due to profound
weakness.

18

Staging
Question 1: How can early bulbar symptoms be
identified?
Stages 1 and 2 - Early intervention
Question 2: What techniques are appropriate for
maintenance of natural speech in progressive dysarthria?
Stages 3 and 4 - Moderate to severe dysarthria
Question 3: Are AAC techniques effective in maintaining
communication in ALS?
Stage 4 and 5: Severe to profound dysarthria
19

How can early bulbar

symptoms be identified?

Laura J. Ball, Ph.D.

Rationale
With the advent of new drug
interventions for ALS, early
diagnosis & identification of
bulbar symptoms has become
critical.
(Quality Standard Subcommittee of the American Academy of
Neurology, 1997)

21

Diagnostic techniques that may

be implemented to facilitate
early identification of bulbar
ALS symptoms have become
essential for pharmaceutical &
communication interventions.
22

Review of literature
In the 1990s, treatments were tested to
slow ALS progression. Decision-making
regarding these interventions requires

information to place these treatments in the

context of other treatments and
to understand the significance of the efficacy
these treatments may show.

Many drug trials target addressing the

earliest possible signs of ALS.
23

Bulbar Characteristics
Speech & swallowing symptoms
usually parallel -- 71% of 200
consecutive visits(Yorkston, Miller & Strand, 1995)
First symptoms involve:
swallowing difficulties
dysarthric speech
possible nasal resonance changes
laryngeal changes
24

Focus on Bulbar Characteristics

of Dysarthria
Neurological or neuromuscular damage
causing paralysis, paresis, or
incoordination in the bulbar or spinal
sensorimotor systems can affect the
range, velocity, force, or timing of speech
movements as well as the respiratory
processes that support speech
production.
(Warren, Rochet, Hinton, 1997, p. 81)
25

ALS Dysarthria Database

N = 218 visits of persons with ALS
documented
Protocol measurement includes numerous
factors including intelligibility, speaking rate,
aerodynamic measures of oral pressure &
nasal air flow, VP descriptor from
aerodynamic measures, communication
effectiveness ratings (self & listener), & ALS
Severity Rating Scale

26

ALS Database Questions

Who is going to need AAC?
How soon do we know they will need AAC?
What will predict loss of intelligible speech
with sufficient time to implement functional
interventions?

Assess
Acquire Device
Training
27

Question 1
Who is going to need AAC?
How do we identify bulbar
characteristics of dysarthria?
How do we assess speech
characteristics?
28

Speech Assessment
Strategies
Intelligibility
Speaking

Rate
Aerodynamic Measurements
Pattern of Velopharyngeal Closure
ALS Speech Severity Scale
Communication Effectiveness
29

Intelligibility
Sentence Intelligibility Test
(Yorkston, Beukelman & Tice, 1991)
Measures

intelligibility in sentences
Scored by unfamiliar (to speaker &
content) listener
Obtain % intelligibility
30

Speaking Rate
Sentence

Intelligibility Test
Speaking rate in sentences
Obtain rate in words per minute

31

Rate & Intelligibility

Changes in speech rate and
oral diadokokinetic rates may
be precursors of changes in
speech intelligibility.
(Yorkston,Strand, Miller, Hillel & Smith, 1993)

32

Rate & Intelligibility

Information obtained from the UNMC
database is consistent with previous
research, in that when rate decreases
to half of normal (or approximately 100
wpm) for an individual with ALS, a
precipitous decline in intelligibility may
be expected.
R2 = .828, p = .000
33

Speaking Rate & Intelligibility

250.00
200.00
150.00

Rate

100.00
50.00
0.00
100

50

Intelligibility

34

Garys Progression
A 40 year old male with bulbar
onset of symptoms.
09/1999: 97% intelligible, rate 90wpm
11/1999: 75% intelligible, rate 68wpm
02/2000: 33% intelligible, rate 52wpm
05/2000:
6.8% intelligible, rate
36wpm
35

Aerodynamic Measurement
Rationale
Accurate

description of speech

deficits
Develop new treatment approaches
Demonstrate quantifiable changes
in physiologic responses
(Warren, Rochet, Hinton, 1997)

36

Aerodynamic Measurement
of Speech Productions
Air

(pneumotachograph with nasal mask)

Normally no flow unless /m, n, /

Air

Flow Meter

Pressure Transducer

(flexible tube placed laterally on tongue)

Normal between 3-8cm H2O)
37

Pattern of VP Closure
Obtained from Aeros printouts.
1. VP closure on pressure consonants
2. Initial VP insufficiency, eventually closes
3. VP insufficiency on some consonants,
approximates but never closes
4. Initial VP closure, insufficient by end of
utterance
5. Excessive VP insufficiency on all
pressure consonants
38

VP Closure & Intelligibility

Consistent with Intelligibility and
Speaking Rate measures, VP closure
and Intelligibility measures remain
fairly steady until the person with ALS
completely and consistently loses
velopharyngeal closure.
R2 = -.393, p=.005
39

VP Closure & Speaking Rate

Examination

of data assessing VP
closure and Speaking Rate indicate a
pattern similar to that identified with
Speaking Rate and Intelligibility.
When Speaking Rate approximates
100wpm, Intelligibility takes a rapid &
precipitous decline.
40

VP Closure & Rate

Likewise, when Speaking Rate approximates
120wpm, the Pattern of VP closure changes
to demonstrate progressively more
consistent VP incompetence. Another
decline is observed at the 100wpm mark.
These data indicate that VP Closure
Pattern/Rate changes precede Intelligibility/
Rate changes in persons with ALS.

41

VP Closure & ALS Speech Rating

Pearson

Product-Moment
Correlation
(R2 = -.417 p = .002)
With increase in VP rating,
observe lower ALS Speech
Ratings
42

Question 2
How soon do we know about the
loss of natural speech?

43

Communication Effectiveness
Modified

Index (Lomas, 1989)

Measure

societal limitation
perceived when communicating
Likert-type scale

10

0 = not at all able

6 = very effective

contextual situations
44

I am effective at conversing with:

1. familiar persons in a quiet environment.
2. strangers in a quiet environment.
3. a familiar person over the phone.
4. young children.
5. a stranger over the phone.
6. while traveling in a car.
7. someone at a distance.
8. someone in a noisy environment.
9. before a group.
10. someone in a long conversation (>1 hour).
45

Intelligibility & Communication

Effectiveness
Communication effectiveness scores
followed a stair-step decline
following a decline in intelligibility.

46

Communication effectiveness
declines occurred at...
1st at 95% > intelligibility
2nd at 90-95% intelligibility
3rd at 80-90% intelligibility
4th at 70-80% intelligibility
Final at < 70% intelligibility

(m = 5.5)!!
(m = 4.7)
(m = 3.7)
(m = 2.3)
(m = 1.5)

47

Intelligibility & Communication

Effectiveness
Communication Effectiveness and
Intelligibility
6
5
4
3
Rating
2
1
Effectiveness
Communication
0
>95%

Self
Listener

9095%

8090%

7080%

<70%

Percent Intelligible

48

Intelligibility & Communication

Effectiveness
With some slight (nonsignificant)
differences, speakers with ALS and
their frequent communication
partners (spouses, children,
caregivers) demonstrate similar
descriptions of communication
effectiveness.
49

Recommendations
It is recommended that evidence-based
speech assessment strategies be
implemented into a protocol to facilitate early
identification of bulbar ALS symptoms.
Early identification may promote earlier
diagnosis of ALS & provide a more
reasonable timeline to physicians wishing to
implement drug trials & patients wishing to
take advantage of them.
50

Maintaining the Use of Natural Speech

(David Beukelman)

Behavioral Interventions

Environmental Interventions

Prosthodontic Interventions

Supplemented Speech Interventions

51

Behavioral Interventions
Speaking rate modification

Speakers usually reduce rate with intervention-especially with cognitive changes.

Maintain coordinated respiratory patterns

Coordinated thoracic and abdominal breath (speech

& grammatical structure)
Reduce fatigue

Conserve energy for communication

Eliminate oral or non-speech exercises

52

Prosthodontic Interventions

Palatal lift

Palatal augmentation (drop-down)

Voice amplification

53

Palatal Lift Evidence

Gonzalez & Aronson (1970).

Aten, et al. (1984).
Esposito et al. (2000) retrospective study
21 of 25 speakers with ALS decreased
hypernasality
2 of 25 refused to wear the lift
4 of 25 received no benefit
Progression of tongue and lip weakness almost always cause
for lack of benefit.

54

Palatal Augmentation

Esposito et al (2000).

55

Environmental Interventions

Optimize hearing of frequent listeners

Optimize adverse speaking situations

Reduce background noise

Mute TV
Amplify speaker in meetings, groups, & noise
Private conference room

56

Supplemented Speech
Interventions

Alphabet Supplementation

Topic Supplementation

Mixed Topic & Alphabet Supplementation

Gestural Supplementation
57

Mutuality Model (Lindbolm, 1990)

Rich

Information
from
Speech
Signal

Un
de
rs

ta n
d in

(Speech
Intelligibility)
Poor
Poor
Rich
Information from Non-speech Sources 58

Speech Impairment
&
Compensatory
Strategies
Acoustic
Signal

Intelligibility

Listener
Processing

Speech
Intelligibility

Language Knowledge
World Knowledge
Disability Knowledge
59

Speech Signal Information

Speech Impairment
&
Compensatory Strategies

Acoustic
Signal

Signal-Independent
Information
Semantic Context
Syntactic Context
Alphabet
Gestures

Listener
Processing

Speech
Comprehensibility

Language Knowledge
World Knowledge
Disability Knowledge

Comprehensibility

60

Alphabet + Semantic Topic Board

Small Talk
Family
Family

Personal
Transportation

Trips
Weather

Food

Church

A B C D E F G
H I J K L M N O
P Q R S T U V
W X Y Z

Sports

Will spell words

Shopping

Point to first letter

Health

Schedule

Yes

Wait

No

Not done
Please stop

Start over Not finished

Forget it

Please repeat
words

Maybe
Dont know

61

Alphabet Supplementation

Beukelman & Yorkston (1977)

42% & 47% improvement in intelligibility (TBI & BS Stroke)
Schumacher & Rosenbek (1986)
57% improvement in intelligibility (PD)
Hustad (1999) (Pilot for Dissertation)
42.5% Improvement in Intelligibility (CP)

Crow & Enderby (1989)

15% Mean improvement in intelligibility (speech signal only) (mixed group of
speakers)

Hustad & Beukelman (Submitted)

19% Mean improvement in intelligibility (Alphabet information with habitual
speech) (CP)

62

Topic Supplementation

(Dongilli, 1994)

63

Topic Supplementation (Cont)

Carter et al. (1996).

Hustad & Beukelman (1998)

9% Mean improvement in intelligibility

10% Improvement in intelligibility

Hustad & Beukelman (Submitted)

10% mean improvement in intelligibility (Topic

information with habitual speech (CP).

64

Semantic
Supplemented Speech
(Hammen, Yorkston, &

Speaker Group

Sentence Intell(%)

Sentence Intell(%)

No Context

Semantic Context

20

Severe

27

67

Moderate

64

96

Dowden, 1991)
Profound

65

Mixed (Topic + Alphabet)

Supplementation
Hunter, Pring, and Martin (1991)

15% relative to topic cues only.

Hustad & Beukelman (Submitted)

34% Mean improvement for mixed

compared to no cues (Mixed cues with habitual

speech) (CP)
66

Gestural Cues

Garcia & Cannito (1996).

25% Improvement in low predictive context

22.5 Improvement in high predictive context

67

Techniques for Improving

Comprehensibility (Speaker-1)
Provide listener with context
Dont shift topics abruptly
Use turn-taking signals
Get your listeners attention
Use complete sentences
Use predictable types of sentences
Use predictable wording
Rephrase you message

Yorkston, Beukelman, Strand, & Bell, 1999

68

Techniques for Improving

Comprehensibility (Speaker--2)
Accompany speech with simple gestures
Take advantage of situational cues
Make environment as friendly as possible
Avoid communication over long distances
Use alphabet board supplementation
Have a handy backup system

Yorkston, Beukelman, Strand, & Bell, 1999

69

Techniques for Improving

Comprehensibility: (Listener-1)
Know topic of conversation
Watch for turn-taking signals
Give your undivided attention
Choose time and place to talk
Watch the speaker
Piecing together the cues
Make the environment work for you
Avoid communicating over long distances

Yorkston, Beukelman, Strand, & Bell, 1999

70

Techniques for Improving

Comprehensibility (Listener-2)
Make sure
your hearing is as good as possible
Decide on and incorporate strategies for
resolving communication breakdowns
Establish some rules of the game
Facilitate communication with others

Yorkston, Beukelman, Strand, & Bell, 1999

71

AAC & ALS

Pam Mathy

72

AAC Methods Used By Individuals Who

Have ALS
(Pam Mathy)
Unassisted methods--these methods do not
involve any form of chart or electronic device
Low tech methods--these methods use some
form of chart (e.g., alphabet board) and some
means to access it (e.g., finger, light pointer,
partner scan). Also included here is
handwriting (e.g., paper, pencil, dry-erase
boards, magic slate)

Laser Pointer With Alphabet

Board

74

Partner Assisted Manual Scan Board

1.
2.

T
H

3.

4.

5.

AND

SPACE

YOU

6.

TO

7.

THE

IT

IN

IS

J
X
Z
GET

IF

BUT

START
OVER

ON

DO

OF

O
F

FOR

BE

I'M

8.

MY

HAVE

WHAT

9.

ME

THAT

CAN

10.

THIS

SO

WILL

DON'T

WITH

LIKE

WAS

GO

NOT

ARE

HOW

OR

75

Partner Assisted Manual

Scanning

76

Handwriting Using White Board

77

AAC Methods Used By

Individuals Who Have ALS

High tech methods--these methods involve use

of an electronic device

Uni-Access Devices: Synthesized Speech Devices

Accessed Primarily Using Manual Direct
Selection (e.g., LightWriter, Link, IMPACT)
Multi-Access Devices: Synthesized Speech
Devices Designed To Support Multiple Access
Methods (e.g., Freedom 2000, DynaVox)

78

Uni-Access Devices:
LightWriter Series--Zygo
Dual display, direct select &
scanning, DECtalk, custom-keyboard
arrangement, very portable, letter-coding,
phrase storage.

79

Uni-Access Devices: Link

Assistive Technology Inc.
Direct-selection
access only,
Letter-coding,
Phrase storage,
DECtalk,
Standard size
keyboard,
Relatively lowcost.

80

Uni-Access Devices: IMPACT

ENKIDU Research
Handheld Portable IMPACT
combines a large keyboard (80%
of full size) with a touchscreen to
provide additional methods of
message production. The
expanded touchscreen means that
you can have more (or larger)
onscreen buttons, allowing for
more varied augmentative
interfaces. With its nylon
carrying case, the Handheld can
be used effectively while
standing or sitting.
Inputs:Touchscreen, keyboard,
scanning.

81

Multi-Access Devices: E Z Keys

for WindowsWords +

82

Multi-Access Devices: DynaVox

Sunrise Medical

83

Switches and Mounts

Slimarmstrong
(Ablenet)

Jellybean switch
(Ablenet)

84

Decision Parameters in AAC

Intervention
Disease

Progression
Employment Status
Age
Motivation to Communicate
Support (family, friend, employer)

85

Disease Progression
Using ALS

severity scale (ALSSS) (Hillel, Miller,

Yorkston, McDonald, Norris & Konikow, 1989

Yorkston,
101

et. al. (1993) followed

individuals

Fifty

eight men
Fifty two women
Across

303 clinic visits

Six

profiles were identified based on Speech,

Upper Extremity and Lower Extremity
Functioning
86

Functioning Cutoffs on ALSSS Used

to Identify Groupings

Adequate speech = 5 or greater (Stages 1 3).

Poor speech = 4 or less (Stages 4 and 5)
Adequate UE = 5 or greater (partial complete
use of UE)
Poor UE = 4 or less (needs assistance in selfcare, cant use pencil/pen)
Adequate LE = 7 or greater (noticeable gait
changes normal ambulation)
Poor LE = 6 or less (impaired mobility--requires
cane, walker, wheelchair)
87

Disease Progression Groupings

Identified by Yorkston, et. al.
Group 1 (46.5%)--adequate speech, adequate UE
Group 2 (20%)--adequate speech, poor UE
Group 3 (16%)--poor speech, adequate UE and LE
Group 4 (8%)--poor speech, adequate UE, poor LE
Group 5 (2.5%)--poor speech, poor UE, adequate

LE
Group 6 (7%)--poor speech, UE and LE

88

AAC Interventions Used by Disease

Progression Group

Group 1 (46.5%)--adequate speech,

adequate UE

None
Portable amplifiers
Alphabet Supplementation

89

AAC Interventions Used by Disease

Progression Group

Group 2 (20%)--adequate speech, poor UE

None
Portable amplifiers
Alphabet Supplementation
Assess for writing augmentation (computer
access) if desired--writing now--speech later

90

AAC Interventions Used by Disease

Progression Group
Group

Low tech alphabet boards/supplementation

Handwriting

3 (16%)--poor speech, adequate UE and LE

Magic slate
White boards

High tech devices depending on needs

Community, work, car

Portable, keyboard-based

Phone

Talking word processors, email for home computer

TTD, FAX

91

AAC Methods Used by Patients With

Bulbar Presentation (Groups 3 & 4)
Facial Exp./Man. Gestures

Yes/No Questions

Hand Writing

Alphabet Board

Multi-Purpose Device

Dedicated Device

B,V

P,G

R,A

C,K

S,D

G,M

M,S

V,L

S,L

K,L

W,G

V,P

x
x

x
x

92

Category of AAC Method(s) Used Most

of the Time by Communicative Activity
Bulbar Presentation Patients
No Tech

Stories

Handwriting

Written Comm

Other Low Tech

In depth Info.

High Tech

Phone

Doesn't Participate

Detailed Needs
Quick Needs
Conversation
0

4
6
8
10
12
Number of Patients (Total N=12)

93

AAC Interventions Used by Disease

Progression Group
Group

4 (8%)--poor speech, adequate UE, poor

LE

Most issues similar to group 3

Portable AAC devices can be mounted on wheelchair

Attention getting devices

94

AAC Interventions Used by Disease

Progression Group
Group

LE

No tech partner dependent auditory scanning

Low tech partner dependent visual scanning
Low tech optical pointing
Portability needs
High tech dedicated and/or multipurpose systems

5 (2.5%)--poor speech, poor UE, adequate

Light weight, portable

Adaptations to home computer

Attention getting devices

95

AAC Interventions Used by Disease

Progression Group

Group 6 (7%)--poor speech, UE and LE

No tech partner dependent auditory scanning

Low tech partner dependent visual scanning
Low tech optical pointing
High tech dedicated and/or multipurpose
systems
Check

needs for portability--wheelchair mounting

Adaptations to home computer

Attention getting devices

96

AAC Methods Used by Patients With

Spinal Presentation (Groups 5 and 6)
Dep. Aud. Scanning
J,P

Facial
Expr.

Yes/No
Question
s x

Yes/No Hier.

Coded EyeBlink

Alphabet Board
(S or D)

Call
Buzzer

Multipurpose
Device

D,D

I,G

C,A

J,M

L,L

L,J-1

O,O

P,M
P,W

L,J-2
E,V

S
D (optical pointer)
x

97

Category of AAC Method(s) Used Most

of the Time by Communicative Activity
Spinal Presentation Patients
No Tech

Stories

Low Tech

Written Comm

High Tech

In depth Info.

Doesn't Participate

Phone
Detailed Needs
Quick Needs
Conversation
0

2
4
6
8
10
Number of Patients (Total N=12)

12

98

Overall AAC Method Use Breakdown by

Communicative Activity (N=6)
100

No Tech

90

Low Tech
High Tech

70
60
50
40
30
20
10
Stories

Detailed Information

Detailed Needs

Basic Needs

0
Conversation

Mean Percentage

80

99

Basic Needs With Stranger

Conversation With Stranger

Basic Needs With

Very Familiar
Partner

Conversation With
Very Familiar
Partner

Mean Percentage

Use of AAC Methods by Partner

Familiarity (N=6)
100

90

No Tech

80

Low Tech

70

High Tech

60

50

40

30

20

10

100

Satisfaction With AAC Methods by

Communicative Activity (N=6)
6

7 (Very Satisfied )

Subjects N=6

4 (Neutral)

1 (Very Dissatisfied)

Written Communication

Stories

Detailed Information

Detailed Needs

Quick Basic Needs

Conversation

101

Related References
Yorkston, Miller, Strand (1995). Management of speech
and swallowing in degenerative diseases. Tuscon, AZ:
Communication Skill Builders.
Warren, Rochet, Hinton. (1997). Aerodynamics. In (M.
McNeil, Ed.) Clinical management of sensorimotor
speech disorders. NY: Thieme.
Lomas, Pickard, Bester, Elbard, Finlayson, & Zoghaib
(1989). The communication effectiveness index:
Development and psychometric evaluation of a
functional communication measure for adult aphasia.
JSHD, 54 (1), 113-124.
102

More references

Mathy, P., Yorkston, K. M., & Gutmann, M. (2000).

Augmentative communication for individuals with
amyotrophic lateral sclerosis. In D. R. Beukelman,
K. M. Yorkston, & J. Reichle (Eds.), Augmentative
communication in adults . Baltimore, MD: Paul H.
Brookes.

Yorkston, K. M., Beukelman, D. R., Strand, E. A., &

Bell, K. R. (1999). Management of motor speech
disorders in children and adults. Austin, TX: Pro-Ed.
103

More references

Miller, R. G., et al. (1999). Practice parameter: The

care of the patient with amyotrophic lateral
sclerosis (an evidence-based review): Report of the
Quality Standards Subcommittee of the American
Academy of Neurology. Neurology, 52, 1311-1323.

Sackett, D. L., Richardson, W. S., Rosenberg, W.,

& Haynes, R. B. (1997). Evidence-based medicine.
New York: Churchill Livingstone.

Yorkston, Beukelman, & Tice. (1991) Sentence

Intelligibility Test. Lincoln, NE: Tice Technologies.
104