This preliminary research report describes the speech characteristics of a 36-year-old male patient (SS) who suddenly began to stutter and experienced a moderate to severe language disturbance immediately following a six-day hospitalization and treatment for his third exacerbation of Multiple Sclerosis. Previous symptomology consisted of lower and upper extremity weakness bilaterally as well as right-side facial numbness and diminished visual acuity. The treatment for previous episodes was Methylprednisolone (high-dose steroid treatment) followed by Prednisone taper and Baclofen in 10 mg dosages (taken as needed) to ameliorate spasticity. No speech or language changes were noted following the two initial episodes.
Treatment during the most recent episode prior the sudden onset of the speech problems consisted of an increase in Baclofen dosage to 30 mg maintained at three dosages daily plus a daily dosage of Tregretol (400 mg) and a 300mg daily dosage of Zantac. Two MRI's were taken subsequent to the medical treatment indicating plaques present in the white matter involving the medulla, cerebellum, basal ganglion, and periventricular white matter. Neurological evaluation showed paleness of the right optic nerve with visual acuity of 20/200 in that eye. No speech abnormality was noted during hospitalization. The speech disturbance appeared on the evening of his hospital discharge during a phone call in which premorbid speech patterns were observed, i.e., most words were repeated several times and speech rate was greatly diminished. One month later, a sample of his conversational speech (247 fluent words) plus a 253-word passage, read aloud, were collected. Three major problem areas were observed: (1) part- and whole-word repetitions, (2) suprasegmental features (stress patterns, slow speech rate, monotonous pitch pattern, and lack of coarticulation), and (3) grammatical deviancies (personal pronoun and determiner omissions or substitutions and verb tense irregularities). Analysis of the repetition behaviors revealed that 213 part- or whole-words were repetitions (46.3%) and 247 (53,7%) words were spoken fluently during conversational speech. About half of the repetitions (48.4%) consisted of part-word; 51.6% were whole-word repetitions. Prolongations, revisions, or sound repetitions were not observed. There no visible sign of "struggle" behaviors associated with speaking. Four multi-syllabic words were pronounced as separate syllable parts, i.e., "supervi-vi-visors" and "apar-par-partment" (syllabification). The total number of iterations per incident for part- and whole-word repetition was similar (101 and 111). The percent of 1 and 2 iterations of the total for part-word repetitions was 87.5% and 82.5% for 1 and 2 iterations of whole-words. The range of iterations varied from 1 to 4 for part-word iterations and 1 to 6 for whole-word iterations. Repetitions occurred in all but one of the 31 utterances. Eighteen percent (19) of the initial words in the utterances contained repetitions while in 15% or 4 of the utterances, repetitions occurred on the last word. The remaining 81 instances of repetitions (78%) occurred between the first word and final words of the utterances. Repetitions were absent as he read aloud the 253-word written passage. He did not appear to be aware that he was repeating syllables or words in conversation. SS was immediately enrolled for speech therapy twice weekly. One pathologist focused upon reducing repetitions while another addressed the language deficiency. To reduce the repetitions, traditional procedures were employed that included prolonging vowels and gentle onset of the initial sound in words. During a sample of conversational speech, taken one month later, the amount of repetitions decreased from 46.3% to 14% during a 277-(fluent)word sample. Twenty-two percent of repetitions occurred on the first word, 8% on the final word, and 70% between these two words. Thirteen of the 23 utterances contained no repetitions.
During the following month, repetitions dropped to only 2.6% and remained below this percentage during the following two sample periods. During the final speech sample, 5 months after therapy was initiated, only 1 word was repeated out of the 270-word sample. SS has not had any reoccurrence of word repetitions for five years
. In the area of suprasegmental features, speech rate, prior to the hospitalization was 189.5 wpm (4.08 sps). During the examination period, rate had dropped to 49.3 wpm (1.85 sps) in conversational speech and 51.5 wpm (1.45 sps) when reading aloud. At the end of the second month, speech rate was basically unchanged at 54.1 wpm (1.29 sys). By the third month, rate had increased to 86.5 wpm (2.16 sys) and 2 weeks later, rate increased to 101.3 wpm. Three weeks later, when he was dismissed from therapy, his average speech rate was 125.9 wpm and reaching 165.5 wpm in one long utterance. SS placed near equal stress on each syllable. Frequently, the pause time between syllables was longer than syllable utterance. For example, the phrase "hot chocolate" was produced as follows (time in seconds is placed below each syllable and pauses between them): hot choc choc o late .13 .60 .22 .64 .20 .29 .20 .16 .12 In this example, there was no coarticulation between syllables . Pauses were used to separate each syllable from the other. Also, there was no evidence of assimilation. For example, "water," usually produced as a voiced /t/ became a distinct aspirated voiceless consonant.
Seven randomly selected utterances were used to sample average fundamental frequency and average loudness levels using the VisiPitch program. The mean fundamental frequency was 106.70 Hz (SD=3.39) with a range of 11.6 Hz from highest to lowest frequency. The mean dB level was 39.47 Hz (SD=.91) , the difference between high and low dB was only 2.5 dB. Pitch and loudness could be described as monotonous and lacking in normal tempo and rhythm.. The language disturbance and the atypical suprasegmental features continued to be a problem during the four-month therapy period but disappeared completely during the Christmas holidays after which final testing was conducted. The major problem areas in language involved omission of determiners (articles "a, the, an"), omission of pronouns "I, his, it, they, my we," and verb irregularities which constituted the bulk of grammatical errors. Verb errors consisted of omission (chiefly the copula), use of irregular negation ("He not go" for "He didn't go"), substitutions of 3rd person singular (likes>like), irregular past (took>take), irregular present (has>have) and regular past (used>use). In addition, a few errors occurred with noun and preposition omissions. Error rate for determiners was consistently high throughout all four monthly sample periods (43% to 82%). Pronouns varied from 23% error in sample one to 63% in sample four over the four months. Verb errors varied from 35% to 69%. No trends were observed. Undoubtedly, difference in topics may account for the variance in error rate. One week prior to the third month in therapy, the physician agreed to reduce the amount of Baclofen that was prescribed. Although there was no immediate improvement in language and rate he was capable of writing in complete sentences. None of the grammatical errors occurred in writing as were occurring in his speech. He seemed to be oblivious to grammatical errors when speaking aloud. During therapy sessions prior to the fourth sample, the therapist noted that SS was beginning to self correct grammatical errors, especially the pronoun "I." At this time, he began to show an awareness of proper stress as emphasis and rhythm improved. During this time, latency in responding was up to 10 seconds. He complained that he experienced a difficult time initiating speech, that is, he knew the appropriate word, but could not utter it. Throughout all of the therapy periods, SS was very cooperative, always willing to work on his speech assignments, and eager to make progress.
Five years after SS recovered his "normal" speech, he reports that he has had no recurrence of similar speech problems whatever. He considers himself completely recovered. It seems likely that the medications prescribed may have played a major role in producing the speech disturbances noted above. Rosenfield,et al., (1994) documented a case of sudden onset of stuttering attributed to administration of Theophylline, an asthma medication. In the field of speech pathology, it is critical to maintain an up-to-date knowledge of medical information. Responsible decisions regarding patient care depend upon the ability to analyze and synthesize a multitude of factors, each contributing it share of input into the individual. The speech pathologist must be non-aggressive, but pro-active with the medical system in the discussion of patient medications and the frequent lack of patient knowledge regarding what pharmacological agents they have been taking and for how long. It is hoped that the detailed description of the speech of this client may serve as an indicator of symptoms to look for when a medication such as Baclofen is prescribed.