The work was supported by NIH grants R01DC013668 (D. Whalen, PI) and R03DC013152 (J. Preston, PI).

Ethics Statement. When used in research, informed consent and/or assent from children is always required before collecting ultrasound images. When used clinically, clients should be informed of the purpose of the ultrasound imaging. Although diagnostic ultrasound imaging is considered &#34;minimal risk&#34; 30, users should always follow the ALARA principle when using ultrasound, meaning exposure to ultrasound should be as &#34;As Low As Reasonably Achievable&#34;31. This involves limiting acoustic ...

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Interspeech. , (2014).</li><li>Shawker, T. H., Sonies, B. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+Biofeedback+for+Speech+Training:+Instrumentation+and+Preliminary+Results.">Ultrasound Biofeedback for Speech Training: Instrumentation and Preliminary Results.</a> Invest Radiol. 20 (1), 90-93 (1985).</li><li>Bacsfalvi, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Attaining+the+lingual+components+of+/r/+with+ultrasound+for+three+adolescents+with+cochlear+implants.">Attaining the lingual components of /r/ with ultrasound for three adolescents with cochlear implants.</a> Can. J. Speech Lang. Pathol. 34 (3), 206-217 (2010).</li><li>Preston, J. L., Brick, N., Landi, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+biofeedback+treatment+for+persisting+childhood+apraxia+of+speech.">Ultrasound biofeedback treatment for persisting childhood apraxia of speech.</a> Am J Speech Lang Pathol. 22 (4), 627-643 (2013).</li><li>Preston, J. L., Leaman, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+visual+feedback+for+acquired+apraxia+of+speech:+A+case+report.">Ultrasound visual feedback for acquired apraxia of speech: A case report.</a> Aphasiology. 28 (3), 278-295 (2014).</li><li>Cleland, J., Scobbie, J. M., Wrench, A. 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Critical Steps within the Protocol
It is essential to obtain clear, interpretable images as described in steps 1.3 and 1.6. Poor image quality renders the procedures meaningless. Additionally, participants must be fully aware of what they are seeing on the screen. Therefore, orienting the participant to the image as described in 3.2 is a step that should be emphasized prior to providing visual feedback training. Additionally, step 3.10, which involves clearly describing differences in tongue shap...

Both clinical and research settings have seen an increase in the use of ultrasound imaging to provide visual biofeedback intervention to individuals with speech disorders. One important use of ultrasound imaging for speech-language pathologists is as a visual biofeedback tool during intervention for individuals with speech disorders. With the guidance of a speech-language pathologist, learners can observe real-time video of the shape and movements of their tongue and discuss how these images may differ from the tongue movements needed to properly articulate a speech sound. To conduct such interventions, it is important for users to be competent in the interpretation of ultrasound images as the tongue moves in real time. Knowledge of the range of correct articulatory patterns used by typical speakers is foundational to recognizing erroneous tongue shapes.
The methods described herein address (a) collecting ultrasound images of the tongue, (b) interpreting ultrasound images associated with both correct and incorrect productions of speech sounds, and (c) using real-time ultrasound imaging as a source of visual biofeedback to facilitate speech production changes in individuals with speech sound errors. Although ultrasound can be used to visualize a variety of lingual phonemes, examples here will focus on ultrasound images of the tongue for the /r/ sound (as in red car), which is described as the most common residual error among children acquiring American English 1. It is also the sound that has been most extensively studied in clinical applications of ultrasound to date. 2-14
One important goal in speech (re)habilitation is to facilitate more intelligible speech by teaching articulatory routines that result in perceptually appropriate productions of a target sound or sequence. Therefore, it is critical to understand tongue actions during normal speech and during production of speech errors. Real-time visualization of the tongue can play a highly beneficial role in encouraging a speaker to modify articulatory movements, as it provides the clinician and client with a shared representation of what is actually happening during speech. Without real-time visualization of the tongue, only static pictures or verbal descriptions of target tongue configurations are available to facilitate understanding of the desired articulatory behaviors. In schema-based models of motor learning, visual information about the movements of the tongue during speech is considered a form of &#34;knowledge of performance&#34; feedback (i.e.&#160;it provides specific qualitative information about the movement that occurred)15. Previous research has indicated that detailed knowledge of performance feedback can facilitate acquisition of a novel motor routine16.
Ultrasound has several advantages over other technologies used to visualize speech. With ultrasound, the entire contour of the tongue can be visualized quickly from tip to root. Preparation for ultrasound imaging generally takes less than a minute.
In contrast, electropalatography (EPG) requires a dental impression and the creation of a customized pseudopalate (which may take weeks), and it can take time to adapt to speaking with the pseudo-palate 17. EPG also enables visualization of tongue-palate contact only in the region covered by the pseudopalate and cannot display the tongue root or the overall shape of the tongue. This limits the nature of what aspects of articulation can be effectively targeted with EPG.
Another alternative is electromagnetic articulography (EMA), which can provide general information about tongue shape and movement 18. However, EMA requires sensors to be glued to the tongue and other structures; thus, the set-up for this type of tongue imaging can take 20 - 30 min&#160;and may not be a viable method for frequent use. Thus, ultrasound may be viewed as more practical.
In the specific context of clinical research on the assessment and treatment of /r/ errors, the use of ultrasound has been reported in several studies for individuals with idiopathic speech sound disorders 2,10,11,13,19, hearing impairment 20, childhood apraxia of speech 12,21, and acquired apraxia of speech following a cerebral vascular accident 22. Studies have also reported the use of ultrasound to treat errors on other lingual phonemes such as /s k g l &#643; &#679; / 23,24. Additional populations that may be candidates include individuals with speech disorders related to cleft palate, or individuals learning pronunciation of sounds in a non-native language 25.
Ultrasound imaging may also be useful diagnostically, e.g., to characterize errors in lingual shapes,26,27, or to identify sub-perceptible or covert contrasts in disordered speech 28,29. If precise articulatory measurements are being obtained and compared, it is essential that the ultrasound be stabilized so that the coordinate space for measurement remains reasonably constant. However, it is generally agreed that an unstabilized probe yields information of sufficient quality for clinical diagnosis and treatment applications, which is the focus of the present paper.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>ACUSON X300&#160; ultrasound with C6-2 probe</td>
			<td>Siemens</td>
			<td>Acuson X300</td>
			<td></td>
		</tr>
		<tr>
			<td>Trasceptic Spray</td>
			<td>Parker labs</td>
			<td>PLI 09-25</td>
			<td></td>
		</tr>
		<tr>
			<td>Acquasonic 100 ultrasound gel</td>
			<td>Parker labs</td>
			<td>01-08</td>
			<td></td>
		</tr>
	</tbody>
</table>

ultrasound images of the tongue: a tutorial for assessment and remediation of speech sound errors

Diagnostic ultrasound imaging has been a common tool in medical practice for several decades. It provides a safe and effective method for imaging structures internal to the body. There has been a recent increase in the use of ultrasound technology to visualize the shape and movements of the tongue during speech, both in typical speakers and in clinical populations. Ultrasound imaging of speech has greatly expanded our understanding of how sounds articulated with the tongue (lingual sounds) are produced. Such information can be particularly valuable for speech-language pathologists. Among other advantages, ultrasound images can be used during speech therapy to provide (1) illustrative models of typical (i.e.&#160;&#34;correct&#34;) tongue configurations for speech sounds, and (2) a source of insight into the articulatory nature of deviant productions. The images can also be used as an additional source of feedback for clinical populations learning to distinguish their better productions from their incorrect productions, en route to establishing more effective articulatory habits.
Ultrasound feedback is increasingly used by scientists and clinicians as both the expertise of the users increases and as the expense of the equipment declines. In this tutorial, procedures are presented for collecting ultrasound images of the tongue in a clinical context. We illustrate these procedures in an extended example featuring one common error sound, American English /r/. Images of correct and distorted /r/ are used to demonstrate (1) how to interpret ultrasound images, (2) how to assess tongue shape during production of speech sounds, (3), how to categorize tongue shape errors, and (4), how to provide visual feedback to elicit a more appropriate and functional tongue shape. We present a sample protocol for using real-time ultrasound images of the tongue for visual feedback to remediate speech sound errors. Additionally, example data are shown to illustrate outcomes with the procedure.

Figure 1 presents sample sagittal images of correct /r/ in a 9-year-old female. The ultrasound images are paired with magnetic resonance images from the same speaker to demonstrate the similar tongue shape that can be viewed with both technologies.
<img alt="Figure 2" src="/files/ftp_upload/55123/55123fig1.jpg" /> 
Figure 1: Sagittal View of a Magnetic Resonance Image during a Correctly Produced Ame...

Watch this Scientific Journal Video about Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors at JoVE.com

Ultrasound Images of the Tongue: A Tutorial for Assessment and Remediation of Speech Sound Errors

Ultrasound imaging can be used to display the shape and movements of the tongue in real time during speech. The images can be used to determine the nature of speech sound errors. Visual feedback of the tongue can be used to facilitate improvements in speech sound production in clinical populations.

Diagnostic ultrasound imaging has been a common tool in medical practice for several decades. It provides a safe and effective method for imaging ...

The overall goal of this procedure is to visualize the tongue with ultrasound during speech, to use this information to evaluate speech errors and provide feedback to patients about their articulation. This method can help answer key questions in the field of speech language pathology. For example, what specifically is the client doing with the tongue while producing a distorted R sound?The main advantage of this technique is that clinicians and researchers now have a way to visualize tongue movements during successful and unsuccessful attempts at a speech sound. The implications of this technique extend to better diagnosis and therapy for clients with speech sound disorders because we no longer have to guess about what's happening with the tongue during speech. Although this method can provide insight into the articulation of R, it's also a practical approach for learning about lingual articulations such as S, K, and L.Begin by positioning the participant comfortably in a chair, with his or her feet on the floor, back straight, and chin slightly forward.Then, place a small amount of ultrasound gel on the ultrasound transducer. Next, position the transducer vertically, making tight contact with the skin underneath the chin, and applying a firm, but not an uncomfortable degree of pressure, to collect a sagittal image and visualize tongue from tip to root. Check the screen to verify that the transducer is properly oriented such that the front of the tongue is on the right of the screen, and the back of the tongue is on the left.Angle the ultrasound transducer slightly forward or slightly back, depending on what part of the tongue is of interest. Instruct the participant to swallow to orient the user to the tongue position relative to the palate. Next, collect coronal images by rotating the ultrasound transducer 90 degrees to capture the tongue from the left to right side.Instruct the participant to sustain sounds requiring midline grooving of the tongue. After imaging is complete, wipe off any excess gel and clean the transducer with the ultrasound-approved disinfecting wipe or spray. Begin by instructing the participant on the proper position of the ultrasound, and allow them to hold the ultrasound transducer.In the sagittal view, observe the tongue between two major shadows created by bone, which is opaque to ultrasound. The shadow of the mandible, and the shadow of the hyoid. Instruct the participant to produce alveolar and velar sounds such as T, D, N, then K and G, to help orient both the participant and the clinician to which side of the image is the anterior tongue tip, and which side is posterior tongue dorsum.In a sagittal view of a correct production of R, check to see that the anterior portion of the tongue elevates, while the back part of the tongue dorsum slopes backwards. To assess distorted R production, instruct the participant to imitate and sustain the R sound.Rrrr. Then, have the participant imitate the R sound in a number of syllables, such as:Ear.Ear.Say rah.Rah. Say ree.Ree. Say roo.Roo.Finally, rotate the probe 90 degrees to obtain a coronal view and observe the lateral margins of the tongue as the participant repeats the syllables er, ar, ear, rah, ree, and roo. Position the probe near the highest point of the tongue, about one-third of the distance between the chin and the throat in the sagittal plane. Orient the participant to ultrasound images in the sagittal section by asking the participant to point to the anterior and posterior regions of the tongue, or, front of the tongue and back of the tongue, respectively.Teach the participant about the different parts of the tongue. Show the participant examples of good image quality and bad. Then, instruct the participant that R requires both an oral constriction in the front, and a pharyngeal constriction in the back.Next, introduce the participant to different tongue shapes for the R sound using drawings, ultrasound images, or magnetic resonance images. Make it clear where the oral and pharyngeal constrictions are, but also acknowledge that every tongue shape is slightly different. Ask the participant to describe two major constrictions for R that are visible in a sagittal section.If the participant cannot identify the oral and pharyngeal constrictions just described, continue to instruct. Then, orient the participant to ultrasound images in coronal section. Instruct the participant of the desired tongue shape from left to right.Ask the participant to trace the tongue shape, identify the left and right edges, identify the center line groove, and explain the desired shape. Have the participant attempt to produce correct R in isolation, or in syllables by providing phonetic cues to copy different tongue shapes. Then, ask him or her to provide an explanation of what they did correctly or incorrectly after some of the attempts.After the participant produces the correct sound, press the pause button to freeze the frame and discuss how this correct image looks different from previous incorrect productions. Finally, allow the participant to practice throughout the session without the ultrasound and offer the opportunity to successfully practice R without visual feedback. Here, a sagittal view of a magnetic resonance image during a correctly produced American English R with ultrasound image of the tongue is shown.Notice the elevation of the anterior tongue and the lowering of the dorsum. On the other hand, in this incorrect or distorted production of the American English R, notice the low tongue tip and blade, and the raised tongue dorsum. This shows the mean accuracy on words containing R across 11 American English-speaking participants who were treated for R distortions.After seven sessions of ultrasound biofeedback therapy, an upward trend in accuracy continues, suggesting that retention and generalization continued to occur. While attempting this procedure, it's important to remember to check the positioning of the probe. Don't let the probe rotate or slide, or the images will become distorted, and will be hard to interpret.Following the use of ultrasound, traditional speech therapy should be included, to encourage successful attempts at speech sounds without visual feedback. Don't forget that ultrasound requires attention to safety, in particular, disinfecting the probe between uses, and also attempting to minimize exposure when possible. After watching this video, you should have a good understanding of how to collect ultrasound images of the tongue, and how to use this information to assess and provide feedback to patients about their tongue movements during speech.

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20.9K visualizações.  Syracuse University. The overall goal of this procedure is to visualize the tongue with ultrasound during speech, to use this information to evaluate speech errors and provide feedback to patients about their articulation. This method can help answer key questions in the field of speech language pathology. For example, what specifically is the client doing with the tongue while producing a distorted R sound?The main advantage of this technique is that clinicians and researchers now have a way to visualize ...