This work has been supported by the National Institute of Health, National Institute on Deafness and Other Communication Disorders, Grant R01DCO09890-02, Canadian Foundation for Innovation (CFI-LOF #15704), and Connaught Foundation, University of Toronto. The authors would like to thank Cynthia Didion, Mili Kuruvilla, Krista Rudy, and Lori Synhorst for assistance with data collection and analysis; and Cara Ullman for creating video clips.
Animations were made by Blue Tree Publishing (<a href="http://www.bluetreepublishing.com/">http://www.bluetreepublishing.com/</a>)
The SPA and SMASH software is Matlab based and can be obtained by contacting Jordan Green at jgreen4@unl.edu. 
Visit our labs:
Bulbar Function Laboratory (Sunnybrook Health Sciences Centre in Toronto, Canada): 
<a href="http://www.sunnybrook.ca/research/?page=sri_groups_bulb_home">http://www.sunnybrook.ca/research/?page=sri_groups_bulb_home</a> 
Speech Production Laboratory (University Nebraska Lincoln): <a href="http://spl.unl.edu">http://spl.unl.edu</a>

I.	Subsystem Analyses

1.	Respiratory subsystem/ Breathing for speech

The respiratory subsystem is evaluated using the Phonatory Aerodynamic System (PAS). The system allows for simultaneous recordings of oral pressure, airflow, and speech acoustics (see Table 1 for the list of equipment and manufacturers). A disposable face mask and a disposable pressure-sensing tube are necessary for recordings. Prior to recording, the flow and pressure channels are calibrated according to the manufacturer's specifications.
<ol>
<li>Vital Capacity (VC) is the maximum volume of air that is exhaled following maximum inhalation. VC is evaluated using a disposable face mask that is attached to the pneumotachograph.
<ol class="lalpha">
<li>The PAS "Vital Capacity" protocol is selected for the recording.</li>
<li>The participant is instructed to inhale as maximally as possible and exhale maximally into the mask; the task is repeated three times.</li>
<li>Maximum expiratory volume is derived using PAS software.</li>
</ol></li>
<li>Subglottal pressure (Ps) is the air pressure available in the lungs for production of "pressure" consonants. Ps is evaluated indirectly by measuring peak pressure in the mouth during the production of a syllable train2,3. 
<ol class="lalpha">
<li>The PAS "Voicing Efficiency" protocol is selected for the recording. </li>
<li>To record the oral pressure during /pa/, the pressure-sensing tube is positioned inside the mouth on the tongue surface. </li>
<li>Nasal passages are occluded with a nose clip to eliminate potential nasal air flow escape.</li>
<li>The participant is instructed to inhale approximately twice their normal amount and say /pa/ into the face mask. The syllable /pa/ is repeated seven times on one exhalation, while maintaining consistent pitch and loudness. The rate is maintained at 1.5 syllables per second.</li>
<li>Peak oral pressure is measured for five (middle) repetitions of /pa/. An average of these five productions is obtained to represent Ps during speech.</li>
<li>Because Ps covaries with sound pressure level (SPL)4,5, the SPL is also collected for each syllable. It is used subsequently as a covariate during analyses.</li>
</ol></li>
<li>Speech breathing is evaluated during connected speech while participants read a standard 60-word paragraph (Appendix 1) developed specifically for accurate, automatic pause-boundary detection6.
<ol class="lalpha">
<li>The PAS "Maximum Phonation" protocol is selected for the recording.</li>
<li>The airflow signal is collected using a disposable mask that is fit around the face.</li>
<li>The participant is instructed to read the paragraph at their normal comfortable speaking rate and loudness.</li>
<li>Air flow traces are exported into a custom-made Speech-Pause Analysis (SPA)7 software program in Matlab. In this program, the pauses in connected speech are identified. The software calculates, among other measures, percent pause time, which is a measure of time spent pausing during the reading of a passage.</li>
</ol></li>
</ol>
2.	Phonatory subsystem

The phonatory subsystem is evaluated via voice recordings using high-quality acoustic recording equipment (Table 1).
<ol class="lalpha">
<li>The microphone is placed approximately 15 cm away from the mouth.</li>
<li>A nasal clip is used to eliminate the potential effect of the velopharyngeal inadequacy on the quality of phonation.</li>
<li>The participant is asked to produce "Maximum Phonation". He or she is instructed to inhale the maximum amount of air and then to phonate /a/ at a normal pitch and loudness for as long as possible. This task is practiced at least once prior to recording. The importance of putting forth maximum effort is emphasized.</li>
<li>Maximum phonation duration is measured in seconds using the acoustic waveform.</li>
<li>The digitized acoustic waveform is loaded into the Multidimensional Voice Profile (MDVP) software for analysis. Measures of central tendency and variability of fundamental frequency (F0), noise-to-harmonic ratio (NHR) and percent jitter, among others, are obtained for the middle five seconds of the phonation interval.</li>
</ol>
3.	Resonatory subsystem

The resonatory subsystem is evaluated using Nasometer. This device consists of a headset with a baffle plate, which is positioned under the nose and separates the oral and nasal cavities. Two microphones that detect the oral and nasal acoustic signals are attached to opposite sides of the plate.
<ol class="lalpha">
<li>The device is calibrated prior to each recording.</li>
<li>The headset is placed on the head with the baffle plate resting above the upper lip and positioned parallel to the ground.</li>
<li>The participant is asked to repeat one "nasal" (e.g., Mama made some lemon jam) and one "non-nasal" (e.g., Buy Bobby a puppy) sentence three times at a habitual speaking rate and loudness.</li>
<li>The measured intensities of the voiced portion of the oral and nasal acoustic signals are converted into a nasalance score, which is defined as the ratio of nasal / nasal+oral acoustic energy, and is expressed as a percentage. The nasalance score reflects the relative proportion of nasal-to-oral acoustic energy in a speech stream8.</li>
<li>The Nasometer software calculates numerous descriptive statistics from the nasalance waveform.</li>
<li>Nasalance distance, which is derived by subtracting the mean nasalance calculated across oral sentences (BBP) from the mean nasalance for the nasal sentences (MMJ)9, can also be used as an index of velopharyngeal impairment.</li>
</ol>
4.	Articulatory subsystem: Face

Facial (lip and jaw) movements are registered in 3D using a high resolution, optical motion capture system10. The infrared digital video cameras capture the positions of 15 reflective markers that are attached to each participant's head and face at specific anatomical landmarks. An acoustic speech signal is recorded simultaneously with speech kinematics.
<ol class="lalpha">
<li>The system is calibrated prior to recordings according to the manufacturer's specifications.</li>
<li>Four markers are attached to the forehead of the participant using a head band. Markers are also attached to the left and right eyebrow, the bridge and tip of the nose, the vermilion border of the upper and lower lip, the left and right corners of the mouth, and to three different locations on the chin. This is the typical marker array used in this protocol, but an unlimited number of markers can be used with this system.</li>
<li>The participant is asked to read sentences and phrases (see Table 2) at their habitual speaking rate and loudness.</li>
<li>A "rest" file recording is obtained and used in post-processing to normalize for differences in marker placement between sessions and for re-expression of the data relative to the consistent anatomically-based coordinate system as needed.</li>
<li>During post-processing, movements of the facial markers are checked for tracking errors and head-corrected based on the subtraction of both the translational and rotational components of head movement.</li>
<li>The data are loaded into SMASH, a Matlab based software program developed in our lab. Within SMASH, the data are filtered and parsed. Peak movement speed is derived from each trace and used as the primary indicator of articulatory function for the jaw and lips. 3D speed is computed as the first-order derivative of each articulator's Euclidian distance time history in SMASH.</li>
</ol>
5.	Articulatory subsystem: Tongue

Tongue tracking is accomplished using an electromagnetic tracking device (WAVE), which records the position and rotation of sensors that are attached to the tongue. Unlike the optical motion tracking that is used to record external, facial structures, the electromagnetic technology provides a way to accurately track tongue movements during speech11.The system uses a combination of 5 and 6-degree-of-freedom (5DOF and 6DOF) sensors to record articulatory motions in a calibrated volume (30 x 30 x 30 cm). Movement data and acoustic data are acquired simultaneously.
<ol class="lalpha">
<li>Two sensors are attached to the articulators using dental glue (PeriAcryl Periodontal Adhesive). One reference is attached to the bridge of the nose to record head movements. One small 5DOF sensor (3D location and 2D angular measurements) is attached to the tongue at midline, approximately 2 cm posterior to the tongue tip.</li>
<li>To obtain tongue movements that are independent from the underlying jaw, each participant is fitted with a pre-made 5 mm bite block. The bite block is made of non-toxic condensation putty (Henry Schein).</li>
<li>The bite block is placed between molars on the side of the mouth. A string attached to the bite block is secured to the participant's face to prevent swallowing of the bite block.</li>
<li>The participant is asked to read sentences and phrases (see Table 2).</li>
<li>Tongue movements are recorded relative to head position.</li>
<li>Post-acquisition, the data is transferred into SMASH, where it is low-pass filtered, parsed based on the vertical movement trace, and used to calculate 3D speed. The average and maximum speed of movement during each utterance is reported as an index of disease-related change of this articulator.</li>
</ol>
II.	System-level Assessment

In addition to the subsystem-level variables, speech intelligibility and speaking rate are measured. These measures are essential because they are current clinical "goal standards" characterizing bulbar speech performance. They provide an indication of the functional status of the speech production system as a whole and quantify the severity of speech impairment. These measures are obtained using the Sentence Intelligibility Test (SIT)12.
<ol class="lalpha">
<li>Prior to recording, a random list of 10 sentences of increasing length (from 5 to 15 words) is generated by the SIT software.</li>
<li>A microphone is placed on the head, approximately 15 cm from the mouth.</li>
<li>The participant is asked to read the list at their habitual speaking rate and loudness. The sentences are digitally recorded at 44.1k using a 16 bit resolution.</li>
<li>Several trained judges who are unfamiliar to the participant transcribe the sentences orthographically and measure sentence durations.</li>
<li>The SIT software automatically calculates speech intelligibility, which is reported as percent of words correctly transcribed out of the total number of words produced. Speaking rate is also reported as the number of words read per minute.</li>
</ol>

<table border="1">
<tbody>
 <tr>
 <td>Subsystem</td>
 <td>Equipment / Software</td>
 <td>Signal</td>
 <td>Acquisition Settings</td>
 </tr>
 <tr>
 <td>Respiratory</td>
 <td>Phonatory Aerodynamic System (PAS), KayPENTAX, Lincoln Park, NJ, USA</td>
 <td>Acoustic, pressure, and flow</td>
 <td>Sampling rate=200 Hz, Low-pass filtered=30Hz</td>
 </tr>
 <tr>
 <td>Phonatory</td>
 <td>Compact flash recorder (E.g., PMD660), 
 Professional quality microphone, 
 SPL meter, Extech Instruments 
 Software: MDVP, KAYPentax</td>
 <td>Acoustic</td>
 <td>Sampling rate=44.01 kHz, 16 bit linear PCM</td>
 </tr>
 <tr>
 <td>Resonatory</td>
 <td>Nasometer, Model 6400, KAYPentax</td>
 <td>Acoustic</td>
 <td>Sampling rate=11025 Hz</td>
 </tr>
 <tr>
 <td>Articulatory: Face</td>
 <td>Eagle Digital System, Motion Analysis Corp. </td>
 <td>Kinematic and acoustic</td>
 <td>Sampling rate=120Hz, Low-pass filtered =10Hz</td>
 </tr>
 <tr>
 <td>Articulatory: Tongue</td>
 <td>WAVE, Northern Digital Inc, Canada</td>
 <td>Kinematic and acoustic</td>
 <td>Sampling rate=100Hz, Low pass filtered=20Hz</td>
 </tr>
</tbody>
</table>
Table 1: Instrumentation and acquisition settings for sub-system data collection
<table border="1">
<tbody>
 <tr>
 <td>Level</td>
 <td>Task</td>
 <td>Measurements</td>
 <td>References &amp; Norms</td>
 </tr>
 <tr>
 <td>Respiratory</td>
 <td>VC</td>
 <td>Maximum expiratory lung volume</td>
 <td>13</td>
 </tr>
 <tr>
 <td>/pa/ x 7</td>
 <td>Subglottal pressure </td>
 <td>2, 3</td>
 </tr>
 <tr>
 <td>Bamboo passage</td>
 <td>% Pause time</td>
 <td>6, 7, 14</td>
 </tr>
 <tr>
 <td>Phonatory</td>
 <td>Maximum phonation /a/</td>
 <td>Maximum phonation duration, mean F0, jitter, SNR</td>
 <td>15, 16, 17, 3</td>
 </tr>
 <tr>
 <td>Resonatory</td>
 <td>Mama made some lemon jam; Buy Bobby a puppy</td>
 <td>Nasalance</td>
 <td>18, 19</td>
 </tr>
 <tr>
 <td>Articulatory: Face</td>
 <td>Buy Bobby a puppy; Say _ again (bat, tide, keep, tool)</td>
 <td>Movement speed</td>
 <td>20, 21</td>
 </tr>
 <tr>
 <td>Articulatory: Tongue</td>
 <td>/ta/ x 5, Say doily again</td>
 </tr>
 <tr>
 <td>System-level</td>
 <td>SIT, Sentences</td>
 <td>Speech intelligibility and speaking rate </td>
 <td>12</td>
 </tr>
</tbody>
</table>
Table 2: Measurements obtained for each subsystem and task

Appendix 1: Bamboo passage
Bamboo walls are getting to be very popular. They are strong, easy to use, and good looking. They provide a good background and create the mood in Japanese gardens. Bamboo is a grass, and is one of the most rapidly growing grasses in the world. Many varieties of bamboo are grown in Asia, although it is also grown in America. Last year we bought a new home and have been working on the flower gardens. In a few more days, we will be done with the bamboo wall in one of our gardens. We have really enjoyed the project.

<ol>
	<li>Ball, L. J., Willis, A., Beukelman, D. R., Pattee, G. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+protocol+for+identification+of+early+bulbar+signs+in+amyotrophic+lateral+sclerosis.">A protocol for identification of early bulbar signs in amyotrophic lateral sclerosis.</a> J. Neurol. Sci. 191, 43-53 (2001).</li><li>Smitheran, J. R., Hixon, T. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+clinical+method+for+estimating+laryngeal+airway+resistance+during+vowel+production.">A clinical method for estimating laryngeal airway resistance during vowel production.</a> J. Speech Hear. Disord. 46, 138-146 (1981).</li><li>Baken, R. J., Orlikoff, R. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Clinical Measurement of Speech and Voice. , (2000).</li><li>Stathopoulos, E. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relationship+between+intraoral+air+pressure+and+vocal+intensity+in+children+and+adults.">Relationship between intraoral air pressure and vocal intensity in children and adults.</a> J. Speech Hear. Res. 29, 71-74 (1986).</li><li>Gauster, A., Yunusova, Y., Zajac, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+speaking+rate+on+measures+of+velopharyngeal+function+in+healthy+speakers.">Effect of speaking rate on measures of velopharyngeal function in healthy speakers.</a> Clin. Linguist. Phon. 24, 576-588 (2010).</li><li>Green, J. R., Beukelman, D. R., Ball, L. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Algorithmic+estimation+of+pauses+in+extended+speech+samples+of+dysarthric+and+typical+speech.">Algorithmic estimation of pauses in extended speech samples of dysarthric and typical speech.</a> J. Med. Speech Lang. Pathol. 12, 149-154 (2004).</li><li>Wang, Y., Green, J. R., Nip, I. S. B., Kent, R. D., Kent, J. F., Ullman, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+of+perceptually-based+and+acoustically-based+inspiratory+loci+in+reading.">Accuracy of perceptually-based and acoustically-based inspiratory loci in reading.</a> Behavior Research Methods. , .</li><li>Fletcher, S. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term="Nasalance"+vs.+listener+judgments+of+nasality.">"Nasalance" vs. listener judgments of nasality.</a> Cleft Palate J. 13, 31-44 (1976).</li><li>Bressmann, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nasalance+distance+and+ratio:+Two+new+measures.">Nasalance distance and ratio: Two new measures.</a> Cleft Palate Craniofac. J.. 37, 248-256 (2000).</li><li>Green, J. R., Wilson, E. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spontaneous+facial+motility+in+infancy:+A+3D+kinematic+analysis.">Spontaneous facial motility in infancy: A 3D kinematic analysis.</a> Dev. Psychobiol. 48, 16-28 (2006).</li><li>Yunusova, Y., Green, J., Mefferd, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+Assessment+for+AG500,+Electromagnetic.">Accuracy Assessment for AG500, Electromagnetic.</a> Articulograph. J. Speech Lang. Hear.Res. 52, 556-570 (2009).</li><li>Beukelman, D., Yorkston, K., Hakel, M., Dorsey, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Speech Intelligibility Test. , (2007).</li><li>Lyall, R. A., Donaldson, N., Polkey, M. I., Leigh, P. N., Moxham, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Respiratory+muscle+strength+and+ventilatory+failure+in+amyotrophic+lateral+sclerosis.">Respiratory muscle strength and ventilatory failure in amyotrophic lateral sclerosis.</a> Brain. 124, 2000-2013 (2001).</li><li>Sapienza, C. M., Stathopoulos, E. T., Brown, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Speech+breathing+during+reading+in+women+with+vocal+nodules.">Speech breathing during reading in women with vocal nodules.</a> J. Voice. 11, 195-201 (1997).</li><li>Hakkesteegt, M. M., Brocaar, M. P., Wieringa, M. H., Feenstra, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+age+and+gender+on+the+dysphonia+severity+index.+A+study+of+normative+values.">Influence of age and gender on the dysphonia severity index. A study of normative values.</a> Folia Phoniatr. Logop. 58, 264-273 (2006).</li><li>Hakkesteegt, M. M., Brocaar, M. P., Wieringa, M. H., Feenstra, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+relationship+between+perceptual+evaluation+and+objective+multiparametric+evaluation+of+dysphonia+severity.">The relationship between perceptual evaluation and objective multiparametric evaluation of dysphonia severity.</a> J. Voice. 4, 529-542 (2007).</li><li>Robert, D., Pouget, J., Giovanni, A., Azulay, J. P., Triglia, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantitative+voice+analysis+in+the+assessment+of+bulbar+involvement+in+amyotrophic+lateral+sclerosis.">Quantitative voice analysis in the assessment of bulbar involvement in amyotrophic lateral sclerosis.</a> Acta Otolaryngol. 119, 724-731 (1999).</li><li>Hardin, M. A., Demark, D. R. V. a. n., Morris, H. L., Payne, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Correspondence+between+nasalance+scores+and+listener+judgments+of+hypernasality+and+hyponasality.">Correspondence between nasalance scores and listener judgments of hypernasality and hyponasality.</a> Cleft Palate Craniofac J. 29, 346-351 (1992).</li><li>Delorey, R., Leeper, H. A., Hudson, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Measures+of+velopharyngeal+functioning+in+subgroups+of+individuals+with+amyotrophic+lateral+sclerosis.">Measures of velopharyngeal functioning in subgroups of individuals with amyotrophic lateral sclerosis.</a> J. Med. Speech Lang. Pathol. 7, 19-31 (1999).</li><li>Tasko, S. M., Westbury, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Speed-curvature+relations+for+speech-related+articulatory+movement.">Speed-curvature relations for speech-related articulatory movement.</a> J. Phon. 32, 65-80 .</li><li>Yunusova, Y., Green, J. R., Lindstrom, M. J., Bal, L. J., Pattee, G. L., aZinman, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Kinematics+of+disease+progression+in+bulbar+ALS.">Kinematics of disease progression in bulbar ALS.</a> J Commun. Disord. 43, 6-20 (2010).</li></ol>

No conflicts of interest declared.

Here we demonstrated a comprehensive protocol for the assessment of bulbar (speech) dysfunction in ALS. The data obtained from this protocol are used to gain a deeper understanding of how ALS affects speech production. These data are also used to identify the most sensitive measures of disease progression. Although this protocol is currently being employed for research, the findings from this research will be utilized to develop more cost-efficient and clinically feasible approaches to quantify bulbar involvement.

<ul>
<li>Equipment / Software</li>
<li>Phonatory Aerodynamic System (PAS), KayPENTAX, Lincoln Park, NJ, USA</li>
<li>Compact flash recorder (E.g., PMD660),</li>
<li>Professional quality microphone,</li>
<li>SPL meter, Extech Instruments</li>
<li>MDVP, KAYPentax</li>
<li>Nasometer, Model 6400, KAYPentax</li>
<li>Eagle Digital System, Motion Analysis Corp.</li>
<li>WAVE, Northern Digital Inc, Canada</li>
</ul>

a protocol for comprehensive assessment of bulbar dysfunction in amyotrophic lateral sclerosis (als)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression across speech subsystems, and for addressing the critical need for sensitive outcome measures for ongoing experimental treatment trials. To address this need, we are obtaining longitudinal profiles of bulbar impairment in 100 individuals based on a comprehensive instrumentation-based assessment that yield objective measures. Using instrumental approaches to quantify speech-related behaviors is very important in a field that has primarily relied on subjective, auditory-perceptual forms of speech assessment1. Our assessment protocol measures performance across all of the speech subsystems, which include respiratory, phonatory (laryngeal), resonatory (velopharyngeal), and articulatory. The articulatory subsystem is divided into the facial components (jaw and lip), and the tongue. Prior research has suggested that each speech subsystem responds differently to neurological diseases such as ALS. The current protocol is designed to test the performance of each speech subsystem as independently from other subsystems as possible. The speech subsystems are evaluated in the context of more global changes to speech performance. These speech system level variables include speaking rate and intelligibility of speech.
The protocol requires specialized instrumentation, and commercial and custom software. The respiratory, phonatory, and resonatory subsystems are evaluated using pressure-flow (aerodynamic) and acoustic methods. The articulatory subsystem is assessed using 3D motion tracking techniques. The objective measures that are used to quantify bulbar impairment have been well established in the speech literature and show sensitivity to changes in bulbar function with disease progression. The result of the assessment is a comprehensive, across-subsystem performance profile for each participant. The profile, when compared to the same measures obtained from healthy controls, is used for diagnostic purposes. Currently, we are testing the sensitivity and specificity of these measures for diagnosis of ALS and for predicting the rate of disease progression. In the long term, the more refined endophenotype of bulbar ALS derived from this work is expected to strengthen future efforts to identify the genetic loci of ALS and improve diagnostic and treatment specificity of the disease as a whole. The objective assessment that is demonstrated in this video may be used to assess a broad range of speech motor impairments, including those related to stroke, traumatic brain injury, multiple sclerosis, and Parkinson disease.

Watch this Scientific Journal Video about A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis ALS at JoVE.com

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis ALS

Objective assessments of the physiological mechanisms that support speech are needed to monitor disease onset and progression in persons with ALS and to quantify treatment effects in clinical trials. In this video, we present a comprehensive, instrumentation-based protocol for quantifying speech motor performance in clinical populations.

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis (ALS)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression ...

a-protocol-for-comprehensive-assessment-bulbar-dysfunction

Research

JoVE Journal

Medicine

33.9K Views.  University of Toronto. Objective assessments of the physiological mechanisms that support speech are needed to monitor disease onset and progression in persons with ALS and to quantify treatment effects in clinical trials. In this video, we present a comprehensive, instrumentation-based protocol for quantifying speech motor performance in clinical populations. 

Video: A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis ALS

Intraspinal Cell Transplantation for Targeting Cervical Ventral Horn in Amyotrophic Lateral Sclerosis and Traumatic Spinal Cord Injury

Respiratory compromise due to phrenic motor neuron loss is a debilitating consequence of a large proportion of human traumatic spinal cord injury (SCI) cases 1 and is the ultimate cause of death in patients with the motor neuron disorder, amyotrophic laterals sclerosis (ALS) 2.
ALS is a devastating neurological disorder that is characterized by relatively rapid degeneration of upper and lower motor neurons. Patients ultimately succumb to the disease on average 2-5 years following diagnosis because of respiratory paralysis due to loss of phrenic motor neuron innnervation of the diaphragm 3. The vast majority of cases are sporadic, while 10% are of the familial form. Approximately twenty percent of familial cases are linked to various point mutations in the Cu/Zn superoxide dismutase 1 (SOD1) gene on chromosome 21 4. Transgenic mice 4,5 and rats 6 carrying mutant human SOD1 genes (G93A, G37R, G86R, G85R) have been generated, and, despite the existence of other animal models of motor neuron loss, are currently the most highly used models of the disease.
Spinal cord injury (SCI) is a heterogeneous set of conditions resulting from physical trauma to the spinal cord, with functional outcome varying according to the type, location and severity of the injury 7. Nevertheless, approximately half of human SCI cases affect cervical regions, resulting in debilitating respiratory dysfunction due to phrenic motor neuron loss and injury to descending bulbospinal respiratory axons 1. A number of animal models of SCI have been developed, with the most commonly used and clinically-relevant being the contusion 8.
Transplantation of various classes of neural precursor cells (NPCs) is a promising therapeutic strategy for treatment of traumatic CNS injuries and neurodegeneration, including ALS and SCI, because of the ability to replace lost or dysfunctional CNS cell types, provide neuroprotection, and deliver gene factors of interest 9.
Animal models of both ALS and SCI can model many clinically-relevant aspects of these diseases, including phrenic motor neuron loss and consequent respiratory compromise 10,11. In order to evaluate the efficacy of NPC-based strategies on respiratory function in these animal models of ALS and SCI, cellular interventions must be specifically directed to regions containing therapeutically relevant targets such as phrenic motor neurons. We provide a detailed protocol for multi-segmental, intraspinal transplantation of NPCs into the cervical spinal cord ventral gray matter of neurodegenerative models such as SOD1G93A mice and rats, as well as spinal cord injured rats and mice 11.

Neural precursor transplantation is a promising strategy for protecting and/or replacing lost/dysfunctional cervical phrenic motor neurons in spinal cord injury (SCI) and the motor neuron disorder, amyotrophic laterals sclerosis (ALS). We provide a protocol for cell delivery to cervical spinal cord ventral horn in rodent models of ALS and SCI.

Respiratory compromise due to phrenic motor neuron loss is a debilitating consequence of a large proportion of human traumatic spinal cord injury (SCI) ...

Clinical Testing and Spinal Cord Removal in a Mouse Model for Amyotrophic Lateral Sclerosis (ALS)

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder resulting in progressive degeneration of motoneurons. Peak of onset is around 60 years for the sporadic disease and around 50 years for the familial disease. Due to its progressive course, 50% of the patients die within 30 months of symptom onset. In order to evaluate novel treatment options for this disease, genetic mouse models of ALS have been generated based on human familial mutations in the SOD gene, such as the SOD1 (G93A) mutation. Most important aspects that have to be evaluated in the model are overall survival, clinical course and motor function. Here, we demonstrate the clinical evaluation, show the conduction of two behavioural motor tests and provide quantitative scoring systems for all parameters. Because an in depth analysis of the ALS mouse model usually requires an immunohistochemical examination of the spinal cord, we demonstrate its preparation in detail applying the dorsal laminectomy method. Exemplary histological findings are demonstrated. The comprehensive application of the depicted examination methods in studies on the mouse model of ALS will enable the researcher to reliably test future therapeutic options which can provide a basis for later human clinical trials.

Clinical Testing and Spinal Cord Removal in a Mouse Model for Amyotrophic Lateral Sclerosis ALS

A mouse model for amyotrophic lateral sclerosis (ALS) is examined clinically and behaviorally. As a prerequisite for an accompanying immunohistological analysis the preparation of the spinal cord is depicted in detail.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder resulting in progressive degeneration of motoneurons. Peak of onset is around 60 ...

Utility of Dissociated Intrinsic Hand Muscle Atrophy in the Diagnosis of Amyotrophic Lateral Sclerosis

The split hand phenomenon refers to predominant wasting of thenar muscles and is an early and specific feature of amyotrophic lateral sclerosis (ALS). A novel split hand index (SI) was developed to quantify the split hand phenomenon, and its diagnostic utility was assessed in ALS patients. The split hand index was derived by dividing the product of the compound muscle action potential (CMAP) amplitude recorded over the abductor pollicis brevis and first dorsal interosseous muscles by the CMAP amplitude recorded over the abductor digiti minimi muscle. In order to assess the diagnostic utility of the split hand index, ALS patients were prospectively assessed and their results were compared to neuromuscular disorder patients. The split hand index was significantly reduced in ALS when compared to neuromuscular disorder patients (P&#60;0.0001). Limb-onset ALS patients exhibited the greatest reduction in the split&#160;hand index, and a value of 5.2 or less reliably differentiated ALS from other neuromuscular disorders. Consequently, the split&#160;hand index appears to be a novel diagnostic biomarker for ALS, perhaps facilitating an earlier diagnosis.

Dissociated atrophy of intrinsic hand muscles, termed the split hand, appears to be a specific feature of amyotrophic lateral sclerosis (ALS).&#160;Consequently, a novel neurodiagnostic test, termed the split hand&#160;index, was developed to quantify the clinical phenomenon of the split hand, which differentiated ALS from mimic disorders.

The split hand phenomenon refers to predominant wasting of thenar muscles and is an early and specific feature of amyotrophic lateral sclerosis (ALS). A ...

The Multiple Sclerosis Performance Test (MSPT): An iPad-Based Disability Assessment Tool

Precise measurement of neurological and neuropsychological impairment and disability in multiple sclerosis is challenging. We report a new test, the Multiple Sclerosis Performance Test (MSPT), which represents a new approach to quantifying MS related disability. The MSPT takes advantage of advances in computer technology, information technology, biomechanics, and clinical measurement science. The resulting MSPT represents a computer-based platform for precise, valid measurement of MS severity. Based on, but extending the Multiple Sclerosis Functional Composite (MSFC), the MSPT provides precise, quantitative data on walking speed, balance, manual dexterity, visual function, and cognitive processing speed. The MSPT was tested by 51 MS patients and 49 healthy controls (HC). MSPT scores were highly reproducible, correlated strongly with technician-administered test scores, discriminated MS from HC and severe from mild MS, and correlated with patient reported outcomes. Measures of reliability, sensitivity, and clinical meaning for MSPT scores were favorable compared with technician-based testing. The MSPT is a potentially transformative approach for collecting MS disability outcome data for patient care and research. Because the testing is computer-based, test performance can be analyzed in traditional or novel ways and data can be directly entered into research or clinical databases. The MSPT could be widely disseminated to clinicians in practice settings who are not connected to clinical trial performance sites or who are practicing in rural settings, drastically improving access to clinical trials for clinicians and patients. The MSPT could be adapted to out of clinic settings, like the patient&#8217;s home, thereby providing more meaningful real world data. The MSPT represents a new paradigm for neuroperformance testing. This method could have the same transformative effect on clinical care and research in MS as standardized computer-adapted testing has had in the education field, with clear potential to accelerate progress in clinical care and research.

The Multiple Sclerosis Performance Test MSPT: An iPad-Based Disability Assessment Tool

Precise measurement of neurological and neuropsychological impairment and disability in multiple sclerosis is challenging. We report methodologic details on a new test, the Multiple Sclerosis Performance Test (MSPT). This new approach to the objective of quantification of MS related disability provides a computer-based platform for precise, valid measurement of MS severity.

Precise measurement of neurological and neuropsychological impairment and disability in multiple sclerosis is challenging. We report a new test, the ...

A Method of Trigonometric Modelling of Seasonal Variation Demonstrated with Multiple Sclerosis Relapse Data

This report describes a novel Stata-based application of trigonometric regression modelling to 55 years of multiple sclerosis relapse data from 46 clinical centers across 20 countries located in both hemispheres. Central to the success of this method was the strategic use of plot analysis to guide and corroborate the statistical regression modelling. Initial plot analysis was necessary for establishing realistic hypotheses regarding the presence and structural form of seasonal and latitudinal influences on relapse probability and then testing the performance of the resultant models. Trigonometric regression was then necessary to quantify these relationships, adjust for important confounders and provide a measure of certainty as to how plausible these associations were. Synchronization of graphing techniques with regression modelling permitted a systematic refinement of models until best-fit convergence was achieved, enabling novel inferences to be made regarding the independent influence of both season and latitude in predicting relapse onset timing in MS. These methods have the potential for application across other complex disease and epidemiological phenomena suspected or known to vary systematically with season and/or geographic location.

Combining plot analysis with trigonometric regression is a robust method for exploring complex, cyclical phenomena such as relapse onset timing in multiple sclerosis (MS). This method enabled unbiased characterisation of seasonal trends in relapse onset permitting novel inferences around the influence of seasonal variation, ultraviolet radiation (UVR) and latitude.

This report describes a novel Stata-based application of trigonometric regression modelling to  55 years of multiple sclerosis relapse data from 46 ...

A Quick Phenotypic Neurological Scoring System for Evaluating Disease Progression in the SOD1-G93A Mouse Model of ALS

The SOD1-G93A transgenic mouse is the most widely used animal model of amyotrophic lateral sclerosis (ALS). At ALS TDI we developed a phenotypic screening protocol, demonstrated in video herein, which reliably assesses the neuromuscular function of SOD1-G93A mice in a quick manner. This protocol encompasses a simple neurological scoring system (NeuroScore) designed to assess hindlimb function. NeuroScore is focused on hindlimb function because hindlimb deficits are the earliest reported neurological sign of disease in SOD1-G93A mice. The protocol developed by ALS TDI provides an unbiased assessment of onset of paresis (slight or partial paralysis), progression and severity of paralysis and it is sensitive enough to identify drug-induced changes in disease progression. In this report, the combination of a detailed manuscript with video minimizes scoring ambiguities and inter-experimenter variability thus allowing for the protocol to be adopted by other laboratories and enabling comparisons between studies taking place at different settings. We believe that this video protocol can serve as an excellent training tool for present and future ALS researchers.

This video protocol describes a sensitive, reliable, and quick method for evaluating the neuromuscular deficits in a transgenic mouse model of amyotrophic lateral sclerosis.

The SOD1-G93A transgenic mouse is the most widely used animal model of amyotrophic lateral sclerosis (ALS). At ALS TDI we developed a phenotypic screening ...

A Protocol for the Use of Remotely-Supervised Transcranial Direct Current Stimulation (tDCS) in Multiple Sclerosis (MS)

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that uses low amplitude direct currents to alter cortical excitability. With well-established safety and tolerability, tDCS has been found to have the potential to ameliorate symptoms such as depression and pain in a range of conditions as well as to enhance outcomes of cognitive and physical training. However, effects are cumulative, requiring treatments that can span weeks or months and frequent, repeated visits to the clinic. The cost in terms of time and travel is often prohibitive for many participants, and ultimately limits real-world access. 
Following guidelines for remote tDCS application, we propose a protocol that would allow remote (in-home) participation that uses specially-designed devices for supervised use with materials modified for patient use, and real-time monitoring through a telemedicine video conferencing platform. We have developed structured training procedures and clear, detailed instructional materials to allow for self- or proxy-administration while supervised remotely in real-time. The protocol is designed to have a series of checkpoints, addressing attendance and tolerability of the session, to be met in order to continue to the next step. The feasibility of this protocol was then piloted for clinical use in an open label study of remotely-supervised tDCS in multiple sclerosis (MS). This protocol can be widely used for clinical study of tDCS.

A Protocol for the Use of Remotely-Supervised Transcranial Direct Current Stimulation tDCS in Multiple Sclerosis MS

The goal of this pilot study is to describe a protocol for the remotely-supervised delivery of transcranial direct current stimulation (tDCS) so that the procedure maintains standards of in-clinic practice, including safety, reproducibility, and tolerability. The feasibility of this protocol was tested in participants with multiple sclerosis (MS).

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that uses low amplitude direct currents to alter cortical ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Using a Chemical Biopsy for Graft Quality Assessment

Kidney transplantation is a life-saving treatment for a large number of people with end-stage renal dysfunction worldwide. The procedure is associated with an increased survival rate and greater quality of patient&#8217;s life when compared to conventional dialysis. Regrettably, transplantology suffers from a lack of reliable methods for organ quality assessment. Standard diagnostic techniques are limited to macroscopic appearance inspection or invasive tissue biopsy, which do not provide comprehensive information about the graft. The proposed protocol aims to introduce solid phase microextraction (SPME) as an ideal analytical method for comprehensive metabolomics and lipidomic analysis of all low molecular compounds present in kidneys allocated for transplantation. The small size of the SPME probe enables performance of a chemical biopsy, which enables extraction of metabolites directly from the organ without any tissue collection. The minimum invasiveness of the method permits execution of multiple analyses over time: directly after organ harvesting, during its preservation, and immediately after revascularization at the recipient&#8217;s body. It is hypothesized that the combination of this novel sampling method with a high-resolution mass spectrometer will allow for discrimination of a set of characteristic compounds that could serve as biological markers of graft quality and indicators of possible development of organ dysfunction.

The protocol presents utilization of the chemical biopsy approach followed by comprehensive metabolomic and lipidomic analysis for quality assessment of kidney grafts allocated for transplantation.

Kidney transplantation is a life-saving treatment for a large number of people with end-stage renal dysfunction worldwide. The procedure is associated ...

Magnetic Resonance Imaging of Multiple Sclerosis at 7.0 Tesla

The overall goal of this article is to demonstrate a state-of-the-art ultrahigh field (UHF) magnetic resonance (MR) protocol of the brain at 7.0 Tesla in multiple sclerosis (MS) patients. MS is a chronic inflammatory, demyelinating, neurodegenerative disease that is characterized by white and gray matter lesions. Detection of spatially and temporally disseminated T2-hyperintense lesions by the use of MRI at 1.5 T and 3 T represents a crucial diagnostic tool in clinical practice to establish accurate diagnosis of MS based on the current version of the 2017 McDonald criteria. However, the differentiation of MS lesions from brain white matter lesions of other origins can sometimes be challenging due to their resembling morphology at lower magnetic field strengths (typically 3 T). Ultrahigh field MR (UHF-MR) benefits from increased signal-to-noise ratio and enhanced spatial resolution, both key to superior imaging for more accurate and definitive diagnoses of subtle lesions. Hence, MRI at 7.0 T has shown encouraging results to overcome the challenges of MS differential diagnosis by providing MS-specific neuroimaging markers (e.g., central vein sign, hypointense rim structures and differentiation of MS grey matter lesions). These markers and others can be identified by other MR contrasts other than T1 and T2 (T2*, phase, diffusion) and substantially improve the differentiation of MS lesions from those occurring in other neuroinflammatory conditions such as neuromyelitis optica and Susac syndrome. In this article, we describe our current technical approach to study cerebral white and grey matter lesions in MS patients at 7.0 T using different MR acquisition methods. The up-to-date protocol includes the preparation of the MR setup including the radio-frequency coils customized for UHF-MR, standardized screening, safety and interview procedures with MS patients, patient positioning in the MR scanner and acquisition of dedicated brain scans tailored for examining MS.

Here, we present a protocol to acquire magnetic resonance (MR) images of multiple sclerosis (MS) patient brains at 7.0 Tesla. The protocol includes preparation of the setup including the radio-frequency coils, standardized interview procedures with MS patients, subject positioning in the MR scanner and MR data acquisition.

The overall goal of this article is to demonstrate a state-of-the-art ultrahigh field (UHF) magnetic resonance (MR) protocol of the brain at 7.0 Tesla in ...