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Comprehensibility of Dysarthric Speech

Article  in  American Journal of Speech-Language Pathology · February 1996

DOI: 10.1044/1058-0360.0501.55

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 Tutorial
Comprehensibility of Dysarthric Speech:
Implications for Assessment and Treatment
Planning
Kathryn M. Yorkston
Edythe A. Strand
Mary R.T. Kennedy
University of Washington, Seattle
This paper describes the concept of
comprehensibility and how it is an important
construct in the assessment and treatment of
dysarthric speech. Intelligibility and comprehen-
sibility are differentiated in terms of their
definition, measurement, and approaches to
treatment. Specifically, comprehensibility is
defined within the World Health Organization
T
he term comprehensibility has been applied to
measurement of the adequacy of communication in
a number of populations, including speakers of
English as a second language and individuals with hearing
impairment. Barefoot and colleagues (Barefoot, Bochner,
Johnson, & vom Eigen, 1993) suggest that comprehensibil-
ity can be defined as “the extent to which a listener
understands utterances produced by a speaker in a commu-
nication context” (p. 32). The notion of communicative
context is not new. Miller and Selfridge (1950) suggest that
total context includes the sum of all conditions surrounding
a communication event. It is the knowledge shared by the
communication partners about the time, place, topic,
purpose, or any other feature of the setting in which the
utterance occurs.
Those who conduct clinical research in dysarthria have
focused more on intelligibility than on comprehensibility.
The term intelligibility refers to the degree to which the
acoustic signal (the utterance produced by the dysarthric
speaker) is understood by a listener. Intelligibility is
typically measured by having listeners orthographically
transcribe words or sentences that the speaker reads. An
intelligibility score is then computed by dividing the
number of words understood by the total number of words
spoken. Because many factors influence intelligibility, a
number of aspects of measurement are typically controlled
(Yorkston, Beukelman, & Traynor, 1984). First, the
speaker’s task is held constant because intelligibility scores
may differ depending on whether the speaker is producing
American Journal of Speech-Language Pathology • Vol. 5 • 1058-0360/96/0501-0055 © American Speech-Language-Hearing
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model of chronic disease as a factor in disability
affecting speech performance in physical and/or
social contexts. The literature related to
comprehensibility of dysarthric speech is
reviewed. Clinical approaches to improving
comprehensibility, including issues of candi-
dacy, intervention planning, and treatment
approaches, are discussed.
words or sentences. Second, the transmission system will
impact intelligibility of the utterance. For example, live
voice will often yield higher intelligibility scores than
transcriptions of tape-recorded utterances. Finally, the
listener’s task will influence intelligibility scores. For
example, forced-choice word selection and sentence
completion will yield higher scores than orthographic
transcription.
The concepts of comprehensibility and intelligibility
may be distinguished by the fact that comprehensibility
incorporates signal-independent information such as
syntax, semantics, and physical context. Figures 1 and 2
illustrate the distinction between speech intelligibility and
comprehensibility as applied to the area of dysarthria. A
review of Figure 1 suggests that speech intelligibility is a
measure of the adequacy of the acoustic signal. It is the
product of at least two components. The first component is
the impairment or the disordered speech production
mechanism. The second component represents compensa-
tory strategies the speaker employs in response to the
impairment. When intelligibility is measured in the clinical
setting, all other signal-independent information is held
constant. For example, information such as semantic
context provided in the natural communication environ-
ment is removed by using standard or randomly selected
words and sentences. Measures of speech intelligibility
have been employed as a gauge of each of its compo-
nents—the impairment and the compensatory strategies
employed by the speaker to improve speech production.
Yorkston • Strand Association
• Kennedy 55
FIGURE 1. A model of factors that contribute to the adequacy
of the acoustic signal and therefore to the speech intelligibility
of dysarthric individuals.
For example, it has been used as an overall indicator of
severity of dysarthria or functional limitation imposed by
the speech impairment (Yorkston, Beukelman, & Bell,
1988). In a recent survey of 10 years of dysarthria research,
speech intelligibility was used as an index of severity in
69% of those manuscripts that reported severity of
dysarthria as a subject descriptor (Strand & Yorkston,
1994). Speech intelligibility has also been used as a
measure of treatment effects. Yorkston, Hammen,
Beukelman, and Traynor (1990) reported changes in
speech intelligibility resulting from reduction in the
speaking rates of individuals with ataxic and hypokinetic
dysarthria. Kennedy, Strand, and Yorkston (1994) used
intelligibility measures as an indicator of changes made by
dysarthric speakers in response to requests for verbal
FIGURE 2. A model of factors that contribute to comprehensi-
bility of dysarthric individuals.
56 American Journal of Speech-Language Pathology • Vol. 5 • No. 1
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repairs and explicit instructions. Intelligibility changes
have been one of the measures used to document other
treatment effects, including increased respiratory/
phonatory effort in Parkinson’s disease (Ramig, 1992;
Ramig, Bonitati, Lemke, & Horii, 1994), palatal lift fitting
(Aten, McDonald, Simpson, & Gutierrez, 1984; Yorkston,
Honsinger, Beukelman, & Taylor, 1989) and increased
physiologic support (Workinger & Netsell, 1992).
Figure 2 illustrates the additional factors that come into
play when considering the concept of comprehensibility.
Note that contextual or signal-independent information is
available to the listener as the acoustic signal is being
heard and processed. This information may take the form
of semantic or syntactic context, cues from the physical
environment, gestures or illustrators, and orthographic cues
such as the initial letters of words. The addition of contex-
tual information provides the listener with additional cues
to supplement the information conveyed by the acoustic
signal. Therefore, the concept of comprehensibility
provides an estimate of the adequacy of performance in
natural communication settings. As rehabilitation special-
ists are being required to document treatment efficacy,
an increased emphasis has been placed on factors that
contribute to enhancement of the overall communicative
effectiveness.
The purpose of this paper is to (a) define comprehensi-
bility within the World Health Organization model of
chronic disease, (b) review the growing literature related to
comprehensibility of dysarthric speech, and (c) discuss
clinical approaches to improving comprehensibility,
including issues of candidacy, intervention planning, and
treatment approaches.
Comprehensibility Within the Model
of Chronic Disease
Because dysarthria is a chronic disorder, the World
Health Organization (WHO) model of chronic disease has
been used as a framework for describing approaches to
assessment and treatment (Yorkston et al., 1988). Recently,
a revised framework was suggested to provide a more
functional perspective (Institute of Medicine, 1991). This
model contains five parameters: (a) pathophysiology
(changes in basic cell or functional physiology); (b)
impairment (loss or change in physiologic function); (c)
functional limitation (restriction or lack of ability to
perform an action or function because of the impairment);
(d) disability (limitations in performance of specific
functions within a natural context); and (e) societal
limitation (changes in performance that limit fulfillment of
social roles or deny access to services).
To illustrate the use of this model for dysarthria, Table 1
contains examples of the levels of deficits, assessment
targets, and approaches to intervention for each of the
parameters of the model. The examples used are taken
from amyotrophic lateral sclerosis (ALS), a progressive
neurologic disease frequently resulting in dysarthria. The
pathophysiologic deficit is degeneration of upper and lower
motor neurons. Assessment targets to determine whether
there is motor neuron degeneration consist of EMG and
February 1996
TABLE 1. A conceptual framework for assessment and intervention in ALS dysarthria. (Adapted from work initially developed by
the Institute of Medicine and published in Disability in America, 1991).

Pathophysiology Impairment Functional Limitation Disability Societal Limitation

Definition Interruption or inter- Loss and/or abnorm- Restriction or lack of Inability or limitation in Restriction, attributable to
ference of normal ality of mental, emo- ability to perform an performing socially social policy or barriers
physiological and tional, physiological, action or activity in defined activities and (structural or attitudinal),
developmental pro- or anatomical struc- the manner or range roles within a social which limits fulfillment of
cesses or structures ture or function, inclu- considered normal and physical environ- roles or denies access to
ding secondary that results from ment as a result of services or opportunities
losses and pain impairment internal or external
factors and their
interplay

Level of deficit Cells and tissues Components of the Speech performance Speech performance Performance of roles by
speech production with full range, speed, in a physical and speakers in social context
process, including strength, & coordi- social context
respiration, phonation, nation
velopharyngeal func-
tion, and oral articula-
tory structures

Examples of Degeneration of upper Changes in respira- Speech intelligibility Comprehensibility Premature retirement
assessment & lower motor tory support
targets neurons through EMG
& clinical observation

Examples of No physiologic inter- Energy conservation Proper phrasing of • Reduction in noise Scaffolding to support work-
approaches vention is currently techniques to com- utterances to high- in the environment related activities
to intervention available for ALS pensate for poor light stress patterning • Partner signals
respiratory support when messages are
not understood so
that repair strategies
can be initiated

clinical observation of spasticity, fasciculations, and
atrophy. Currently, there is not intervention at this physi-
ologic level. The impairment associated with dysarthria in
ALS results from deficits in respiration, phonation,
velopharyngeal function, and/or oral articulation. Ap-
proaches to the assessment and treatment of the impair-
ment have been described elsewhere (Rosenbek &
LaPointe, 1985; Yorkston et al., 1988). Using the example
of dysarthria associated with ALS, the assessment target
for understanding the contribution of reduced respiratory
support to the speech impairment may include measure-
ment of vital capacity, sustained phonation time, and
phrase length. Intervention at the level of the impairment
might include training the use of energy conservation
techniques to compensate for poor respiratory support. For
the parameter of functional limitation, the level of deficit
refers to how well the dysarthric speaker can perform
movements to produce the intended acoustic output. At this
point, measures such as speech intelligibility are targets of
assessment. An example of intervention at this level might
be encouraging the speaker to use proper phrasing in order
to highlight stress patterning, thus improving speech
intelligibility.
If functional limitation is defined as performance of an
activity, the disability is the performance of that activity in
a natural setting or context. We are recommending that the
term comprehensibility be used to indicate the adequacy of
speech performance in a social context. An example of
intervention at this level might be the reduction of noise in
the environment during communicative exchanges.
Another example of intervention at the level of disability
might be teaching the communication partner to signal
when messages have not been understood so that strategies
for repair can be initiated. The final level in this framework
is societal limitation. This implies the restriction of a
speaker’s ability to perform societal roles because of the
dysarthria. With some recent exceptions (King, Ramig,
Stein, & Dereshiwsky, 1994), there are no structured
approaches for measurement of such limitations in
dysarthria. Until better measures are available, we must
rely on activities such as interviews regarding recreation,
home maintenance, or vocational roles. Intervention at the
level of societal limitation may take the form of develop-
ment of scaffolding to support work-related activities or
educating employers about the removal of barriers to
communication.
Studies of Comprehensibility
in Dysarthria
There are many reports in the field of dysarthria that
focus on speech intelligibility. Studies of children (Kent,
Miolo, & Bloedel, 1994) and of adults (Yorkston, Dowden,
& Beukelman, 1992) have been reviewed elsewhere. The
focus of the following section will be on those studies that
measure speech intelligibility in the context of some type
of signal-independent information. The term that we are
applying to this topic is comprehensibility.

Yorkston • Strand • Kennedy 57

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Semantic Context FIGURE 3. Single word intelligibility scores for the No Context
and Context condition when subjects were grouped according
The contribution of semantic context to intelligibility to dysarthria severity. (Reprinted with permission, Hammen et
has perhaps received the most substantial research atten- al., 1991.)
tion. Hammen and colleagues (Hammen, Yorkston, &
Dowden, 1991) studied the impact of semantic categories
on judges’ ability to understand single words produced by
21 individuals with moderate to profound dysarthria. The
semantic categories were developed by asking responders
to provide prototypical examples of words or phrases in 60
common semantic categories. Table 2 contains examples of
six semantic categories and the set of 12 words or phrases
most commonly provided for that category. Dysarthric
speakers produced a list of 50 words randomly selected
from semantic categories such as these. Three judges
orthographically transcribed the word lists, first without
semantic context and then with the context provided.
Results displayed in Figure 3 suggest that word intelligibil-
ity increased with semantic context for all severity groups:
speakers with profound, severe, and moderate dysarthria.
The largest difference was noted for the severe group,
where scores improved by 40.2%.
In extending the study of the effects of semantic context
on speech intelligibility, Dongilli (1994) examined single
words and target words embedded in sentences produced
severity from mild to profound. Results indicated that
by eight individuals with flaccid dysarthria ranging in
severely dysarthric speakers benefited the most from
TABLE 2. Examples of semantic contexts and words or
semantic cues, whereas mildly dysarthric speakers ben-
phrases provided most frequently. Lists are presented in efited the least. Overall, listeners’ knowledge of the
alphabetical order. (Adapted from Hammen et al., 1991.) semantic context improved speech intelligibility; however,
the effect was greater for single words than for words
Something embedded in sentences. The author suggests that perhaps
Men Wear Kind of Ice Cream Holidays the benefit of knowing the syntax of the sentence overshad-
owed any benefit that the semantic cue provided, particu-
Coat Banana Christmas
larly for mildly involved speakers. The implication of this
Hat Cherry Easter
finding is that listeners not only use semantic context but
Jacket Chocolate Father’s Day
also sentence structure to determine the content of the
Pants Coffee Halloween
message.
Shirt Mint Independence Day
Shoes Mocha Labor Day
Shorts Neopolitan Memorial Day Syntactic Context
Socks Peach Mother’s Day
Carter and colleagues (Carter, Yorkston, Strand, &
Sweater Pecan New year’s Day
Hammen, 1996) argue for the importance of syntactic as
Tie Raspberry Thanksgiving
well as semantic cues for improving the intelligibility of
Undershirt Strawberry Valentine’s Day
dysarthric speech. Sentence production samples were
Vest Vanilla Veterans’ Day
obtained from three speakers with moderate dysarthria
(sentence intelligibility scores 70–82%) and from three
Type of Bird Colors Household Appliances
speakers with severe dysarthria (sentence intelligibility
Bluejay Black Blender scores 30–40%). Judges listened and orthographically
Cardinal Blue Dishwasher transcribed the sentences under three conditions: no
Crow Brown Dryer context, semantic context, and syntactic context. For
Eagle Green Freezer example, for the sentence “The police said the collision
Hawk Grey Microwave was not my fault,” the semantic cue was “accident,” and
Heron Orange Mixer the syntactic cue was “ The _____ _____ the _____ was
Owl Pink Oven not my _____.” Results indicated that both semantic and
Parakeet Purple Refrigerator syntactic cues improved the sentence intelligibility of
Parrot Red Stove severely but not moderately involved dysarthric speakers.
Robin Tan Television One possible explanation for the lack of effect for the
Seagull White Toaster moderate group is that the sentences were fairly under-
Sparrow Yellow Washer standable (70–82% intelligibility) based on the acoustic
signal alone. The addition of semantic and syntactic cues

58 American Journal of Speech-Language Pathology • Vol. 5 • No. 1 February 1996

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did not enhance the comprehensibility of the message
further. For the severely impaired group, a number of
possible mechanisms might be responsible for the im-
provement. Semantic context may increase the predictabil-
ity of stimuli and decrease the need to rely on the acoustic
signal. The mechanism for the benefits of syntactic
context may be somewhat different. Syntactic context may
help the listener identify the boundaries of linguistically
meaningful units, thus improving speech intelligibility. In
other words, syntactic context may assist the listener in
parsing the distorted acoustic signal into the appropriate
units.
Gestures
In addition to studying the influence of predictiveness
and knowledge of the contextual situation, Garcia and
Cannito (1996) investigated benefits of naturally occurring
gestures called illustrators. Illustrators are defined by
Ekman and Friesen (1969) as movements that are directly
tied to speech by serving to visually illustrate what is
spoken verbally. For example, for the sentence “Stop and
turn around where you are,” the illustrators were palm
extended in a halting motion and then circular motion of
the index finger. The authors speculated that such illustra-
tors have the potential of enhancing intelligibility either by
supplying additional semantic information or by reorganiz-
ing and modifying the speech production, as was suggested
by Rosenbek (1984). Garcia and Cannito conducted two
experiments. In one, the extent to which speech production
was improved by having the speaker produce simple
gestures as he spoke was studied. In this experiment, all
visual cues were removed, and judges listened to audio-
tapes of habitual speech and speech produced with illus-
trating gestures. No difference between the two production
conditions was noted. Thus, speech production had not
FIGURE 4. Sentence intelligibility scores of a 62-year-old man
with flaccid dysarthria. Low and high predictive sentences
were produced with and without gestures. (Adapted from
Garcia & Cannito, 1996.)
Downloaded from ajslp.asha.org on April 30, 2010
improved. In the other experiment, judges viewed video-
tapes as they made their judgments. Results are displayed
in Figure 4 for low predictive and high predictive sen-
tences. Note the marked differences in speech intelligibility
between the conditions. When the listener’s knowledge
was maximized through the speaker’s use of gestures and
high message predictiveness, there was a 70% gain in
intelligibility. These differences are especially impressive
since the speech acoustic signal apparently had not
improved.
Orthographic Cues
The role of orthographic cues in enhancing the intelligi-
bility of severely dysarthric speakers was reported by
Beukelman and Yorkston (1977). Two speakers with
acquired dysarthria, one as the result of a brain stem stroke
and the other a traumatic brain injury, were recorded as
they read sentences, once as they did habitually (unaided
condition) and once as they pointed to the first letter of
each word on an alphabet board (aided condition). Judges
orthographically transcribed the sentences produced in the
unaided and the aided conditions. In addition, judges
transcribed the samples in a third condition (board con-
cealed). In this condition, the speech samples recorded for
the aided condition were presented to the judges with the
portion of the video monitor showing the spelling board
concealed. The third condition was added in an effort to
understand the influence of the rate reduction that occurred
as speakers used the alphabet board to identify initial
letters of words. Results are displayed in Figure 5. Note
that a marked improvement in sentence intelligibility was
noted when speakers pointed to the alphabet board and
judges were able to see the additional orthographic
FIGURE 5. Sentence intelligibility for speakers N and H under
three experimental conditions: Unaided (habitually produced),
Aided (pointing to the first letter of each word on an alphabet
board) and Board Concealed (same as Aided except that the
judge could not see the alphabet board). (Adapted from
Beukelman & Yorkston, 1977.)
Yorkston • Strand • Kennedy 59
information (aided condition). Because there was no
difference between the unaided and board concealed
condition for speaker N, the increase in intelligibility
appears to be due to the additional information provided by
the board rather than by improved production at slowed
speaking rates. For speaker H, both rate reduction and
orthographic supplementation appear to contribute to
improved intelligibility. In 1989, Crow and Enderby also
reported consistent changes in word and sentence intelligi-
bility using alphabet supplementation.
The Physical Environment
For many years, clinicians have appreciated the impor-
tance of the environments in which speakers with
dysarthria are attempting to communicate. Berry and
Sanders (1983) reviewed principles of “environmental
education” in which factors such as predictability of the
situation, noise, lighting, distance, and posture are exam-
ined in order to develop an appropriate intervention plan.
Recent surveys of individuals with dysarthria have
confirmed the importance of environmental factors. When
asked for their perspective on what factors make communi-
cation situations difficult (Yorkston, Bombardier, &
Hammen, 1994), dysarthric individuals indicate greatest
difficulty on items characterized by “environmental
adversity.” These items include situations such as “Chat-
ting with someone while riding in a car,” and “Having a
conversation at a social gathering while others are nearby
and the room is dimly light.” Many of the environmental
conditions described by Berry and Sanders are represented
in these items.
Although the literature regarding the comprehensibility
of dysarthric speech is not extensive, there is growing
evidence to suggest that many signal-independent factors
have potential for influencing the understandability of
speakers with dysarthria. Information may take the form of
semantic, syntactic, orthographic, or gestural context. How
these factors can be incorporated into a treatment program
will be discussed in the following section.
Clinical Implications
Perhaps the most fundamental clinical implication of the
notion of comprehensibility is the fact that it provides the
functional perspective so important in today’s health care
environment. It is likely that failure to assess and treat at
the level of disability such as comprehensibility will affect
reimbursement for clinical services. Further, bringing
about functional changes is at the heart of our clinical
practice. In this section, issues of candidacy and specific
strategies and their implementation into an overall treat-
ment plan will be discussed.
Candidacy
What are the characteristics of speakers with dysarthria
who would likely benefit from an intervention focusing on
improved comprehensibility? Support for the importance
of severity of dysarthria as a factor in candidacy decisions
60 American Journal of Speech-Language Pathology • Vol. 5 • No. 1
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comes from theoretical models, data-based research, and
clinical impressions.
From a theoretical perspective, the model of mutuality
proposed by Lindblom (1990) provides some insight into
the relationship between severity of dysarthria and the
importance of contextual information. Figure 6 illustrates
the relationship between the information from the acoustic
signal, speech intelligibility, signal-independent informa-
tion, and contextual information. If the signal information
is rich and speech intelligibility is high, then comprehensi-
bility is high even in the face of restricted contextual
information. However, as the richness of the information
from the acoustic signal is degraded, as in severe
dysarthria, the signal-independent information becomes
more critical for maintenance of comprehensibility.
Results from the research literature cited above also
suggest that severity of the dysarthria plays an important
role in predicting the benefits of contextual information.
Relying exclusively on this literature, one would predict
greatest benefits for individuals with moderate to severe
dysarthria. In other words, the speech of individuals with
mild dysarthria may not be sufficiently distorted to cause
listeners to have difficulty accurately understanding the
message. The literature would suggest that speech intelligi-
bility of mildly dysarthric speakers does not improve with
contextual information, perhaps because their speech is
already nearly completely intelligible. On the other end of
the severity continuum, profoundly dysarthric speakers
tend not to benefit greatly from contextual information,
perhaps because their speech is so distorted that listeners
become confused by receiving additional information to
process in light of the severely degraded acoustic signal.
Caution is warranted in interpreting this literature. The
literature does not address the important issue of listener
burden. Contextual information may reduce the burden of
communication placed on the listener and thus make
overall communication exchanges easier. Likewise, for
FIGURE 6. The contribution of information from the acoustic
signal and the signal-independent information to the compre-
hensibility of the dysarthric speaker. (Adapted from Lindblom,
1990.)
February 1996
individuals with profound dysarthria, the small changes in
speech intelligibility brought about by context may prove
functionally important.
Other factors, such as level of cognitive functioning,
may also make certain individuals with dysarthria better
candidates than others for intervention focusing on
maximizing comprehensibility. Providing communication
partners with the appropriate semantic, syntactic, gestural,
or other contextual information is a complex activity. It has
been our clinical experience that these skills develop
spontaneously in only the most cognitively-intact individu-
als. Another factor to consider is the speaker’s level of
experience with the dysarthria. Individuals who acquire
dysarthria as an adult must learn to manage communication
situations differently than prior to the disorder. Skills for
managing conversation when one must rely on a highly
distorted speech signal are different from the skills needed
in normal interaction. Again, it is our clinical experience
that the most successful users of signal-independent infor-
mation are those with the most practice. Vogel and Miller
(1991) also suggest that speakers’ ability to use this type of
information may be compromised as a result of aging,
dementia, aphasia, and right hemisphere dysfunction.
In summary, we have used a theoretical model, research
findings, and clinical impressions to develop a profile
characterizing the ideal candidate for use of signal-
independent information to improve comprehensibility.
This candidate would have long-standing, moderate to
severe dysarthria and would have the cognitive skills
necessary to develop strategies to compensate for a highly
distorted speech signal.
Strategies to Enhance Comprehensibility of
Dysarthric Speech
Before we present some specific techniques for enhanc-
ing comprehensibility, it is useful to discuss a general
approach to treatment planning in this area. Recall that the
goal of this type of intervention is to improve performance
in natural communication environments. In other words,
we are seeking to enhance performance in many situations,
including home, work, or public accommodations, talking
with one person or with many, talking to family, friends, or
strangers, talking in noisy situations or quiet ones, in face-
to-face situations or in situations where communication
partners cannot see one another. Because the number of
potential communication situations is large, clinicians
cannot hope to develop precise plans for each situation.
Rather, treatment planning should be considered a partner-
ship between clinicians, clients, and their families. The
clinician’s role in this partnership is to provide the client
with a framework for evaluating each communication
setting and to develop strategies that are appropriate for
that situation (Francis Tucker, personal communication,
1994). When given a suitable background, clients and their
families will often find solutions that extend well beyond
those that the clinician would have developed indepen-
dently. Further, they will readily adapt principles they learn
to new or different situations.
The Communication Partner. Readers will note that
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different terms have been applied when discussing the
communication recipient. When discussing speech intelli-
gibility, the term listener has usually been employed,
implying that the individual is attending to the acoustic
signal in an effort to understand it. When discussing
comprehensibility, on the other hand, the term communica-
tion partner will be employed. The important role of the
communication partner in establishment of psychosocial
well-being has been highlighted in treatment approaches
for individuals with aphasia (Lyon, 1989, 1991). The term
communication partner implies an active alliance between
the communicators with shared communicative responsi-
bility. The following section will highlight the role of
communication partners in intervention. In our experience,
treatment aimed at improving comprehensibility is best
accomplished within communication dyads. Consistently
bringing the major communication partners(s) into the
treatment process is essential to achieving improved ability
to convey communicative intent in natural environments.
Several factors are important to emphasize with
communication partners of dysarthric speakers: (a) their
role in improving comprehensibility, (b) procedures for
manipulating the environment, (c) techniques involved in
maximizing hearing acuity, and (d) strategies to be adapted
for dealing with communication breakdown. Initially, it is
important to make the point that it is not the dysarthric
client who comes for treatment to improve comprehensibil-
ity, but the communicating “pair.” In other words, treat-
ment is focused on a process that involves both partners, as
speakers and listeners. The nondysarthric partner has an
important role in maximizing communication efficiency.
Examples of areas of responsibility include: making sure to
be in the same room when initiating conversation; making
sure to watch the face of the dysarthric speaker as he or she
talks; and not initiating conversation while the dysarthric
speaker is eating or drinking. Manipulation of the environ-
ment, although seemingly simple, can greatly enhance
comprehensibility. Turning down the radio or television,
making sure the lighting is adequate, and avoiding noisy
environments (e.g., a room full of people talking) during
conversation are examples of ways to make the environ-
ment facilitate communication. It is also important for the
communication partner of a dysarthric speaker to make
sure their hearing acuity is maximized. Even mild hearing
loss can impede the listener’s ability to make maximum
use of the acoustic signal.
Strategies for dealing with communication breakdown
should be determined and agreed on by both the dysarthric
speaker and the communication partner. Examples of such
strategies include: (a) having the listener signal in some
predetermined way that the message was not understood;
(b) agreeing to repeat the message one time (using learned
strategies that maximize the acoustic signal); (c) if the
message is still not understood, adopt an agreed on back up
method, such as rephrasing the message using different
syntax, or perhaps substituting a synonym, or spelling
problematic words. Appendix A contains a checklist for
communication partners of dysarthric speakers. These
items can be used in treatment and given to the client to
take home. In our experience, strategies for improving
Yorkston • Strand • Kennedy 61
comprehensibility are often based on common sense. It is
not difficult for dysarthric speakers and their communica-
tion partners to understand the techniques and how and
when to use them. It does require changing old patterns of
habitual communication styles, which can be very difficult
to change. For example, one couple did most of their
communicating during the evening meal. Although it was
obvious that this was becoming more and more difficult
due to the increasing dysarthria of a degenerative disease,
both partners found it uncomfortable to set aside another
time, in a quiet room, to communicate the events of their
day. As a result, patients often report that although they
know what to do, they haven’t really used the strategies at
home. Treatment, therefore, should also include discussion
regarding ways to implement these changes in a manner
that will work for each person’s lifestyle.
The Speaker With Dysarthria. Because adults with
acquired dysarthria already have a tremendous fund of
knowledge related to language and the communication
process, they can use this knowledge to their advantage.
An excellent framework for developing a plan to improve
the comprehensibility of dysarthric speech is presented by
Vogel and Miller (1991). They describe a knowledge-
driven or “top-down” approach to treatment. The term top-
down is used to refer to “the cognitive process of using
available information to construct a gestalt, or whole” (p.
89). Using their model, a “bottom-up” approach would
involve the listener’s attempt to understand the acoustic
signal, whereas a “top-down” approach would involve
using whatever contextual information is available.
Appendix B contains a checklist of techniques that we
use as a starting point for our discussions with clients.
Many of these techniques follow from knowledge of
semantics, syntax, phonology, and pragmatics of language
processing described by Vogel and Miller (1991). Exami-
FIGURE 7. A schematic representation of approaches to intervention for individuals with severe dysarthria.
62 American Journal of Speech-Language Pathology • Vol. 5 • No. 1
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nation of this checklist will reveal that not all of the
suggestions are appropriate for every individual with
dysarthria. Rather, the clinical discussion may focus on
which of these may be useful and which would not. We
have provided this information in a checklist format
because clients and their families tell us that having written
information to review at their leisure is helpful to them.
The Role of Comprehensibility in the Overall
Treatment Plan
Many approaches to treatment are available to individu-
als with dysarthria. Some of these approaches are illus-
trated in Figure 7, which depicts the dysarthria on one side
of a scale as a heavy weight tipping the balance against the
speaker. The weight is heavier with severe dysarthria.
None of the clinical interventions currently available are
sufficient, by themselves, to tip the balance in favor of the
speaker. Therefore, treatment planning in dysarthria can be
conceptualized as a process of finding and placing a
number of small weights on the other side of the scale to
counterbalance the weight of the disorder.
Some of the most effective of these treatment tech-
niques have as their goal improved speech intelligibility or
increasing the adequacy of the acoustic signal. Speech
intelligibility may be improved by reducing the level of
impairment, for example, strengthening the weak oral
muscles of an individual with a brainstem stroke. Intelligi-
bility may also be improved by developing compensatory
strategies such as increasing vocal loudness by increasing
the level of effort of a speaker with Parkinson’s disease.
Most of the individuals with dysarthria questioned about
what compensatory strategies they found most useful
suggested that “improved production” was more effective
for them than strategies such as those that relate to environ-
February 1996
ment modification, partner instruction, or other factors FIGURE 8. (top) Word intelligibility as judged by familiar and
(Yorkston et al., 1994). unfamiliar listeners with and without semantic context for ND.
(bottom) Word intelligibility for CM with and without semantic
Other interventions for dysarthria, such as those context. CM produced the words either with a palatal lift or
discussed in the previous section, have as their goal without it (Adapted from Yorkston et al., 1992).
improved comprehensibility of communication. These
strategies include reduction of environmental adversity,
providing semantic or syntactic cues, or using gestures to
illustrate utterances. When used singly, each of the
strategies depicted in Figure 7 may have only a small
effect; however, when used in combination, they may bring
about important changes. Although this is often the case,
note that effects of multiple treatment approaches may not
always be more powerful than single approaches. For
example, those dysarthric speakers who have concomitant
cognitive impairment may benefit from single strategies.
Use of multiple approaches can be illustrated by
considering two cases (Yorkston et al., 1992). The first
case, ND, was a 57-year-old women with cerebral palsy
and severe dysarthria who used an augmentative communi-
cation device while communicating with acquaintances but
relied on natural speech most of the time with her family.
Figure 8 (top) illustrates word intelligibility scores with
and without semantic context for unfamiliar and familiar
listeners. Note that intelligibility scores were near zero for
both listening groups without context. Although the
addition of context improved intelligibility scores for both
groups of listeners, familiar listeners benefited more than
did unfamiliar ones. In another case, CM, a woman many
years postonset of traumatic brain injury, was fitted with a
palatal lift to compensate for poor velopharyngeal function.
Word intelligibility scores are illustrated in Figure 8 (bottom)
with and without semantic context. Note that neither inter-
vention applied singly had a marked effect. The difference
between the No lift and Lift condition (without context) was
only 3%, whereas the difference between the Without
Context and With Context condition was 15%. However,
combining the two conditions, Lift and Context, results in
55% improvement over the habitual condition.
In summary, attention to improving comprehensibility
has a role in intervention planning for many dysarthric
speakers. It becomes critically important for some catego-
ries of speakers with dysarthria. The first category includes
speakers whose dysarthria is so severe that all possible
interventions to counterbalance the heavy weight of the compehensibility are not yet available. However, instru-
impairment must be brought into play. The second and ments such as the Communicative Effectiveness Index
perhaps related category includes speakers for whom (Lomas et al., 1989) and the ASHA Functional Assessment
improving the adequacy of the speech signal is not a of Communications Skills for Adults (FACS; Thompson,
realistic goal. As an example, individuals in this category Frattali, & Holland, 1995) could be implemented as part of
might be speakers with moderate to severe dysarthria a battery of assessment tools. It is clear, however, that
associated with ALS. For these individuals, reducing their more work needs to be done to refine measurement
impairment is not an intervention goal because of the techniques for assessing overall comprehensibility as well
relentlessly progressive nature of their disorder. Because of as the effectiveness of treatment of comprehensibility.
their intact cognition and gradual onset of the dysarthria, Although speech intelligibility is one measure that contrib-
these individuals may also have already spontaneously utes information to the overall comprehensibility of a
developed whatever compensatory strategies are available communication message, it should not be the only means
to them for improving speech production. Intervention for of determining the success of the interaction. Analysis of
them may involve planning approaches to improve the comprehensibility should focus on the success of the
comprehensibility of communication. communication exchange and include such indicators as
A number of future research and clinical directions are the behaviors of the communication partner in response to
apparent. For example, standardized measures of the message. Measures of the perceived burden of the

Yorkston • Strand • Kennedy 63

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communication task for both the speaker with dysarthria
and the communication partner are also needed. Does this
burden change as the severity of the dysarthria changes?
What is the relationship between this burden and overall
quality of the communication, for the speaker with
dysarthria and the communication partner? Answers to
these and other questions will assist in the development of
speech intervention with goals to improve communication
effectiveness and ultimately quality of life.
Acknowledgment
Preparation of this work was supported in part by NIDCD
grant 1K08 DC00043-01A1.
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Appendix A
Techniques for Improving Comprehensibility: For the Communication Partners of the Dysarthric Speaker
Communication is a partnership. The following techniques may
make the communication process easier. The items that are
checked may be the most appropriate for you.
❏ Make sure you know the general topic of the conversation.
Knowing the topic of conversation makes a big difference in
understanding speech that is distorted. Encourage speakers
with dysarthria to introduce topics.
❏ Watch for turn-taking signals. Some speakers with dysarthria
for whom speech is slow have difficulty getting a turn in a
conversation. Watch carefully for your partner’s signals or
decide in advance on some turn-taking signals.
❏ Give your undivided attention. Speech is usually so easy to
understand that listeners can do other things and still under-
stand what is being said. Speech that is slow and distorted is
more difficult to understand and therefore, requires our
undivided attention.
❏ Picking the time and place for communication. Most of us
can talk all day without getting tired. Most of us can do many
things while we talk. We can walk and talk, chew gum and talk,
or eat and talk. Talking may be a very difficult task for a speaker
with dysarthria. Avoid important conversations when the
speaker is tired. Mealtimes may no longer be the best time for
conversation.
❏ Watch the speaker. All of us get a considerable amount of
information by watching a speaker. When speech is slow or
distorted, it is even more important to look at the speaker’s
face.
❏ Piecing together the cues. Some people describe the task of
understanding slow and distorted speech as a process of
piecing together a series of cues. Some of the cues, of course,
come from speech. Other cues may come from the gestures
that the speaker may use or from the physical surroundings.
Take advantage of whatever cues are available to you.
❏ Make the environment work for you. Maximize your ability to
understand the speaker with dysarthria by making sure you
have enough light; that the light is on the speaker’s face; and
that all extraneous noise is eliminated or reduced.
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Taylor, T. (1989). The effects of palatal lift fitting on the
perceived articulatory adequacy of dysarthric speakers. In K.
M. Yorkston & D. R. Beukelman (Eds.), Recent advances in
clinical dysarthria (pp. 85–98). Boston: College-Hill.
Yorkston, K. M., Miller, R. M., & Strand, E. A. (1995).
Management of speech and swallowing disorders in degenera-
tive disease. Tucson, AZ: Communication Skill Builders.
Received April 21, 1995
Accepted October 10, 1995
Contact author: Kathryn Yorkston, PhD, Rehabilitation Medicine,
RJ-30, University of Washington, Seattle, WA 98195. E-mail:
yorkston@u.washington.edu
Key Words: comprehensibility, intelligibility, dysarthria
❏ Avoid communication over long distances. Make sure to
always be in the same room when you initiate conversation. It is
difficult for many speakers with dysarthria to speak loudly
enough to be heard in another room.
❏ Make sure your hearing is as good as possible. It is
important that you hear well. If you suspect you have even a
mild hearing loss, have your hearing tested. Properly fitted
hearing aids may make the speech of individuals with dysarthria
more understandable.
❏ Decide on and incorporate strategies for resolving
communication breakdowns. There may be times when you
will not be able to understand some or all of a message. It is
important to develop a plan of action to take if this happens.
Some people find the following steps helpful in preventing
frustration:
• Signal as soon as you don’t understand. (Most people find
that a nonverbal signal is best because it does not disrupt
the flow of conversation).
• Let the speaker know the parts of the message that you did
understand. (In this way, the speaker will not have to repeat
the entire message.)
• Let the speaker repeat the misunderstood words one time.
• If you still don’t understand, ask the dysarthric speaker to go
to a predetermined “back up” plan that involves perhaps
rephrasing, verbal spelling, or writing.
❏ Establish some rules of the game. Speakers with dysarthria
may have some very definite preferences about what they
would like you to do and what they wish you would not do.
Knowing these preferences may reduce frustration. For
example, does the speaker with dysarthria want you to guess or
not? want you to finish sentences or not?
❏ Facilitating communication with others. Communicating with
people who are unfamiliar to them is difficult for many dysarthric
speakers. You may be of assistance as a translator in some
situations. Again, it is useful to have some predetermined
guidelines. Does the dysarthric speaker want you to translate
misunderstood parts of the message? to provide long or
elaborate responses to questions when you know what the
answers are? to order food in a restaurant?
Yorkston • Strand • Kennedy 65
Appendix B
Techniques for Improving Comprehensibility: For the Dysarthric Speaker
(Adapted from Vogel and Miller, 1991; and Yorkston, Strand, and
Miller, in press).
The following techniques may be useful for individuals whose
natural speech may at times be difficult to understand. The items
that are checked may be the most appropriate for you. These
techniques enhance the understandability of your speech by
providing your communication partner some extra cues:
❏ Provide your communication partner context for what you
are saying. Knowing the topic of conversation makes a big
difference in understanding speech that is distorted. If your
speech is difficult to understand, provide the context by writing
or spelling the topic of your message.
❏ Don’t shift topics abruptly. If your speech is difficult to
understand, your partners may get lost if you change from one
topic to another without a transition. Let people know that you
are changing topic and what the new topic is.
❏ Turn-taking signals. Conversations tend to go very quickly. If
your speech is slow, you may need to use clear signals that you
want a turn. These signals may take the form of an eye gaze, a
breathing pattern, a body movement, a gesture, or verbal
interjection. Choose one or two that work for you and make
sure listeners are aware of them.
❏ Get your listener’s attention. It is impossible for any listener
to understand unless he or she is paying attention. If your
speech is difficult to understand, it is even more important that
listeners are paying attention. Before you begin a message,
alert your communication partner by saying his or her name.
❏ Use complete sentences. Grammatically complete sentences
are usually easier for listeners to understand. Avoid telegraphic
sentences or those in which the “little” grammatical words are
deleted.
❏ Use predictable types of sentences. Simple, grammatically
predictable sentences are generally easier to understand than
longer grammatically complicated sentences.
❏ Use predictable wording. There are many ways to communi-
cate a single idea. If your speech is difficult to understand,
avoid unusual idioms or slang expressions. Be direct. For
example, “Close the window, please,” may be easier to
understand than, “I wouldn’t mind if you would close the
window.”
❏ Watch the tone of your voice. We communicate much
information by changing the tone of voice. For example, the
phrase “You really look terrific” may mean two completely
different things depending on how you say it. If you have
66 American Journal of Speech-Language Pathology • Vol. 5 • No. 1
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difficulty expressing subtle changes in meaning with your
intonation, you’ll need to express sarcasm or humor in other
ways.
❏ Rephrase your message. If listeners have not understood you
even after you’ve repeated the message, try communicating the
thought using different words. But use a signal to let them
know.
❏ Accompany speech with simple gestures when appropri-
ate. At times, speech may be supplemented by simple
gestures. For example the palm extended in a halting motion,
then a circular motion with index finger may accompany the
message, “Stop and turn around where you are.”
❏ Take advantage of situational cues. Your surroundings may
help you give a listener extra cues. For example, you might
point to objects in the room in order to introduce a topic.
❏ Make the environment as “friendly” as possible. Some
communication environments are more difficult than others.
Avoid carrying out important conversations in noisy places or in
places where your communication partner cannot watch you as
you speak, for example, in dimly lit rooms or in situations where
your listener is a long distance from you.
❏ Avoid communication over long distances. Trying to speak
with someone who is across the room or in another room is
difficult. If you need to call attention to yourself, a buzzer,
beeper, or baby monitor may be useful.
❏ Alphabet board supplementation. If your speech is very
difficult to understand, you may want to point to the first letter of
each word as you say it. This reduces your speaking rate,
allowing weakened muscles more time to formulate the precise
movements of the speech sounds. It also provides the listener
with information about the word being spoken. If a word is not
understood even when the first letter of the word has been
identified, you can resolve the misunderstanding by spelling out
the word in its entirety.
❏ Communicating emotional messages. Take care to commu-
nicate “emotionally loaded” messages when you are not tired
and when there is plenty of time.
❏ Have a handy backup system. Have a highly understandable
communication system handy in case of difficulty. This may be
as simple as a pad of paper and pencil to write cue words.
Generally, we advise speakers with dysarthria not to let their
listener get absolutely lost. Understanding little or nothing of a
message can be very frustrating to a listener. If you see that
someone is not understanding you, stop and make sure that he
or she understands before you continue.
February 1996
 Comprehensibility of Dysarthric Speech: Implications for Assessment and Treatment
Planning

Kathryn M. Yorkston, Edythe A. Strand, and Mary R.T. Kennedy

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