Loud Speech Research Articles

Intuitive visualizations of pitch and loudness in speech.

Visualizing acoustic features of speech has proven helpful in speech therapy; however, it is as yet unclear how to create intuitive and fitting visualizations. To better understand the mappings from speech sound aspects to visual space, a large web-based experiment (n = 249) was performed to evaluate spatial parameters that may optimally represent pitch and loudness of speech. To this end, five novel animated visualizations were developed and presented in pairwise comparisons, together with a static visualization. Pitch and loudness of speech were each mapped onto either the vertical (y-axis) or the size (z-axis) dimension, or combined (with size indicating loudness and vertical position indicating pitch height) and visualized as an animation along the horizontal dimension (x-axis) over time. The results indicated that firstly, there is a general preference towards the use of the y-axis for both pitch and loudness, with pitch ranking higher than loudness in terms of fit. Secondly, the data suggest that representing both pitch and loudness combined in a single visualization is preferred over visualization in only one dimension. Finally, the z-axis, although not preferred, was evaluated as corresponding better to loudness than to pitch. This relation between sound and visual space has not been reported previously for speech sounds, and elaborates earlier findings on musical material. In addition to elucidating more general mappings between auditory and visual modalities, the findings provide us with a method of visualizing speech that may be helpful in clinical applications such as computerized speech therapy, or other feedback-based learning paradigms.

Loudness of temporally varying environmental sounds

Loudness of speech, speech-like signals, and other dynamic environmental sounds were measured and compared to predictions of current loudness models and predictions on the basis of the relevant standards. Loudness was assessed experimentally by using a loudness matching procedure and categorical loudness scaling. The scaling method used in our study is in agreement with the requirements of the international standard on categorical loudness scaling. Categorical scaling allows for a fast assessment of loudness over a large level range but has the disadvantage that loudness is not measured in sones, as commonly used in loudness models. The data of the two methods are compared by deriving levels at equal loudness from the categorical loudness data. In addition, the present study discusses to what extend the scaling data can be compared to loudness predictions by using recently proposed equations relating categorical units to sones. The comparison of the measured levels at equal loudness and simulations revealed that for speech and speech-like signals the long-term spectrum largely determines the loudness of the sound. Dynamic models with short time constants tend to overestimate loudness. In general, this is also true for the other environmental sounds although for some technical signals discrepancies remain.

Análise da variação prosódica em diferentes estilos de reportagens telejornalísticas

Objetivo Caracterizar reportagens telejornalísticas de estilo sério, neutro e descontraído, de forma perceptivo-auditiva, e identificar acusticamente sua variação prosódica.Métodos Na primeira fase, foram selecionados 30 offs de reportagens de sites de canais abertos, posteriormente divididos em três grupos de estilos: sério, neutro e descontraído. A amostra final foi definida por meio do julgamento de 20 sujeitos leigos, que escolheram os cinco melhores offs para cada estilo. Na segunda fase, três fonoaudiólogas avaliaram a amostra de forma perceptivo-auditiva e, na terceira fase, foi realizada análise acústica dos parâmetros de frequência fundamental, intensidade e duração.Resultados Nos três estilos, a amostra foi representada por uma qualidade vocal neutra, com curva melódica equilibrada, uso de ênfases conforme importância da palavra na frase, pausas expressivas e velocidade de fala média. Na análise acústica, o estilo sério mostrou menores valores de frequência mínima, de variação de intensidade e de duração da sílaba tônica. O estilo neutro obteve os menores valores de frequência máxima, de variação em semitom, de quantidade de pausas por minuto e maior variação de intensidade e de taxa de elocução. O estilo descontraído obteve a menor taxa de elocução e as maiores frequências máxima, mínima, variação em semitons, quantidade de pausas por minuto e duração da sílaba tônica. Houve diferença estatística na taxa de elocução, quando comparados os estilos descontraído e sério e descontraído e neutro.Conclusão A avaliação perceptivo-auditiva obteve resultado igual em todos os estilos. Na análise acústica, a taxa de elocução diferenciou os estilos sério e neutro do estilo descontraído.

Examining the relationship between speech intensity and self-rated communicative effectiveness in individuals with Parkinson's disease and hypophonia

PurposeTo examine the relationship between speech intensity and self-ratings of communicative effectiveness in speakers with Parkinson's disease (PD) and hypophonia. An additional purpose was to evaluate if self-ratings of communicative effectiveness made by participants with PD differed from ratings made by primary communication partners. MethodsThirty participants with PD and 15 healthy older adults completed the Communication Effectiveness Survey. Thirty primary communication partners rated the communicative effectiveness of his/her partner with PD. Speech intensity was calculated for participants with PD and control participants based on conversational utterances. ResultsResults revealed significant differences between groups in conversational speech intensity (p=.001). Participants with PD self-rated communicative effectiveness significantly lower than control participants (p=.000). Correlational analyses revealed a small but non-significant relationship between speech intensity and communicative effectiveness for participants with PD (r=0.298, p=.110) and control participants (r=0.327, p=.234). Self-ratings of communicative effectiveness made participants with PD was not significantly different than ratings made by primary communication partners (p=.20). ConclusionsObtaining information on communicative effectiveness may help to broaden outcome measurement and may aid in the provision of educational strategies. Findings also suggest that communicative effectiveness may be a separate and a distinct construct that cannot necessarily be predicted from the severity of hypophonia.

The Effect of a High Upper Input Limiting Level on Word Recognition in Noise, Sound Quality Preferences, and Subjective Ratings of Real-World Performance.

One important factor that plays a role in front-end processing is the analog-to-digital converter within current hearing aids. The average input dynamic range of hearing aids is 96 dB SPL with an upper input limiting level (UILL) of 95-105 dB SPL. The UILL of standard hearing aids could distort loud signals, such as loud speech or music, which have root-mean-square values of 90 and 105 dB SPL with crest factors of 12 dB SPL to 14-20 dB SPL, respectively. This indicates that these loud sounds could create a distorted signal for patients when the input limiting level is reached. To examine if significant differences in word recognition in noise, sound quality preferences, and subjective ratings of real-world performance exist between conventional and high UILL hearing aids. Words in noise and sound quality preferences were assessed using recordings on a Knowles Electronic Manikin for Acoustic Research with conventional and high UILL hearing aids, different microphone modes, and listening conditions. Participants wore the hearing aids for 2 mo and completed questionnaires on subjective performance. Ten adults with bilateral slight to moderately severe sensorineural hearing loss were recruited. A four-factor repeated-measures analysis of variance (ANOVA) revealed significant differences between the conventional and high UILL across microphone modes and listening conditions for words in noise [F(2, 18) = 6.0; p < 0.05]. A three-factor repeated-measures ANOVA for sound quality preferences revealed a significant difference only for presentation level [F(1, 9) = 81.0; p < 0.001]. A one-factor ANOVA did not reveal significant differences between the conventional and high UILL on subjective ratings of real-world performance. Word recognition and sound quality preferences revealed significant differences between the conventional and high UILL; however, there were no differences in subjective ratings of real-world performance. One participant preferred the conventional UILL, two the high UILL, and seven thought performance was equal, which may be due to the listening environments participants encountered, as evidenced by datalogging.

Behavioral treatments for speech in Parkinson's disease: meta-analyses and review of the literature.

Parkinson's disease (PD) results from neurodegenerative processes leading to alteration of motor functions. Most motor symptoms respond well to pharmacological and neurosurgical treatments, except some axial symptoms such as speech impairment, so-called dysarthria. However, speech therapy is rarely proposed to PD patients. This review aims at evaluating previous research on the effects of speech behavioral therapies in patients with PD. We also performed two meta-analyses focusing on speech loudness and voice pitch. We showed that intensive therapies in PD are the most effective for hypophonia and can lead to some improvement of voice pitch. Although speech therapy is effective in handling PD dysarthria, behavioral speech rehabilitation in PD still needs further validation.

Acoustic effects of loud speech across vowels and speakers

Although loud speech is widely agreed mainly to involve increased respiratory driving support leading to greater acoustic intensity, past work suggests that speakers may make laryngeal and supralaryngeal adjustments as well. For example, previous studies suggest that loud speech is accompanied by greater jaw displacements as well as formant frequency variation, especially in the form of higher first formants. Acoustic studies have generally not sampled widely across the vowel space, however. This study assessed how formants, f0, duration, and intensity varied across conversational and loud conditions, with a particular focus on formant frequencies. Eleven German-speaking women performed three speaking tasks: Reading, answering questions, and recounting a recipe. Target words included a range of high, low, tense, and lax vowels. Loudness variation was elicited naturalistically via changing interlocutor distance. Initial results from the reading and question-answer tasks suggest that formant frequencies vary on average in louder speech, particularly for F1, but the effects are speaker-dependent and may also differ between high vs. low and tense vs. lax vowels. These acoustic data will ultimately be combined with simultaneously recorded data on intraoral pressure, vocal-fold contact, and breathing kinematics to assess the range of speakers' strategies for achieving louder speech.

Vocal comfort and effort in speech: Accommodation to different room acoustic conditions

Background: Vocal effort is a physiological entity that accounts for variation in voice production as loading increases, measured as sound pressure level (SPL). A number of studies have investigated vocal effort and load, but few have considered the role of acoustic clarity (C50), the early to late arriving sound ratio. Method: 20 subjects performed vocal tasks in various room acoustic conditions. Tasks were performed in three styles: soft style, comfortable conversational style, and loud classroom style. C50 in the position of the talker was changed by means of two reflective panels. Two noise levels were used: background noise, and artificial child babble noise. After each task, the subject answered questions addressing their perception of vocal comfort, control and fatigue. SPL and Fundamental Frequency (F0) were measured. Results: When panels were present, talkers perceived the room as being more comfortable to speak in. In particular, in the babble condition and in loud speech, comfort and control tended to increase. Vocal effort (SPL) tended to decrease when panels were present. An assessment of F0 is also reported. The results indicate that even while keeping reverberation time constant, reflective surfaces may be optimized to increase voice comfort and reduce vocal effort.

Cutaneous vibration enhances the Lombard Effect

The Lombard Effect is traditionally defined as a compensatory vocal response to noise at the ear. Somatosensory feedback is also relevant to speech, however, and may be expected to play a role in the Lombard response and perceived vocal effort. The effect of masking both auditory and laryngeal vibrotactile feedback was assessed in adults without speech or hearing disorders. Autophonic loudness, speech intensity, fundamental frequency, and formant frequencies were measured in each of three conditions: unmasked, auditory masking, and mixed auditory plus somatosensory masking. Neither the slope of the autophonic loudness curve nor the shape of the oral reading intensity contour changed as a function of masking condition. However, the intercept of the autophonic loudness curve and the offset of the intensity contour were greater in the mixed masking as compared to the auditory masking condition, indicating that vibrotactile masking effectively enhanced the Lombard Effect. These findings support the hypothesis that both auditory and somatosensory feedback function to adjust speech gain, without affecting relative production intensity or autophonic loudness perception. As such, the Lombard Effect is proposed to result from a general sensorimotor process rather than from a specific audio-vocal mechanism.

Secondary Mania and Tapentadol

Introduction Tapentadol is a centrally-acting synthetic analgesic which acts as a mu-opioid receptor agonist as well as a norepinephrine re-uptake inhibitor. It is use to treat cronic pain. Most prevalence adverse effects are gastrointestinal and nervous symptoms. Furthermore, it has objectified, with less frequency, psychiatric disturbances. Objetives To analyse the relationship between a maniac episode and tapentadol. Methods Forty-nine-year-old female, with personal history of dyslipidemia and lumbar herniated discs in L4-L5, L5-S1, in treatment with tapentadol 200 mg/day for 20 days and no past psychiatric history. She was admitted to the Psychiatry Department due to a maniac episode, with desinhibition, pressure and loud speech, euphoria, megalomaniac delusion and sleep disturbance for the last 10 days. Young Mania Rating Scale (YMRS) was 36 points. Olanzapina 15 mg/day was introduced and tapentadol was removed. Symptoms remitted quickly and 6 days later, at discharge, YMRS was 4 points. One year later, the patient continued to be asymptomatic. Results Opioids can produce psychiatric disorders like hallucination, sleep disorders, depressed mood, disorientation, agitation, nervousness, restlessness, euphoric mood. Secondary mania to tapentadol mechanism is unknown, but having opiate cases described, it is possible to attribute this episode to tapentadol. Conclusions – Secondary mania is associated with various medical conditions, including vitamin B12 deficiency, brain injury, HIV infection and drugs such as alcohol, caffeine, sympathomimetics, steroids, bupropion, isoniazid, clarithromycin and opioids. – Further research is required to determine if the maniac episode was only isolated by the tapentadol or it is the beginning of a bipolar disorder.

Impact of the LSVT on vowel articulation and coarticulation in Parkinson’s disease

The purpose of this study was to investigate the impact of the Lee Silverman Voice Treatment (LSVT®) on vowel articulation and consonant–vowel (C–V) coarticulation in dysarthric speakers with Parkinson’s disease (PD). Nine Quebec French speakers diagnosed with idiopathic PD underwent the LSVT®. Speech characteristics were compared before and after treatment. Vowel articulation was measured using acoustic vowel space and calculated with the first (F1) and second formant (F2) of the vowels /i/, /u/ and /a/. C–V coarticulation was measured using locus equations, an acoustic metric based on the F2 transitions within vowels in relation to the preceding consonant. The relationship between these variables, speech loudness and vowel duration was also analysed. Results showed that vowel contrast increased in F1/F2 acoustic space after administration of the LSVT®. This improvement was associated with the gain in speech loudness and longer vowel duration. C–V coarticulation patterns between consonant contexts showed greater distinctiveness after the treatment. This improvement was associated with the gain in speech loudness only. These results support the conclusions of previous studies investigating the relationship between the LSVT®, speech loudness and articulation in PD. These results expand clinical understanding of the treatment and indicate that loud speech changes C–V coarticulation patterns. Clinical applications and theoretical considerations are discussed.

An Improved Frequency-Shift Compression Method Based on Auto Energy Gain Compensation for Digital Hearing Aids

Sensorineural hearing impaired individuals have narrow hearing range, especially in high frequency. Due to acoustic diffusion masking, just amplifying speech can’t meet patients’ demands. Traditional methods restore the signal of high frequency in low frequency, which has two weaknesses. On the one hand high frequency covers low frequency, on the other hand the methods change the energy of speech. These two aspects severely decrease speech loudness, perception and recognition. To solve the above problems, we have proposed an improved frequency shifting compression method based on Auto Energy Gain Compensation (AEGC) which is used for hearing aids. Fully investigating the relationship of speech frequency with energy and recognition, the scheme selectively keeps the information of vital frequency band. Meanwhile, it compensates the speech loudness with AEGC module. With the proposed scheme, it has obviously improved the speech perception and recognition. Both the theoretical simulation result and subjective test in APP on android platform show the energy is compensated and the speech recognition ratios are enhanced 20%-30% in different environments, especially efficient in quiet, noisy and normal environment.

Subjective assessment of cochlear implant users' signal-to-noise ratio requirements for different levels of wireless device usability.

In order to better inform the development and revision of the American National Standards Institute C63.19 and American National Standards Institute/Telecommunications Industry Association-1083 hearing aid compatibility standards, a previous study examined the signal strength and signal (speech)-to-noise (interference) ratio needs of hearing aid users when using wireless and cordless phones in the telecoil coupling mode. This study expands that examination to cochlear implant (CI) users, in both telecoil and microphone modes of use. The purpose of this study was to evaluate the magnetic and acoustic signal levels needed by CI users for comfortable telephone communication and the users' tolerance relative to the speech levels of various interfering wireless communication-related noise types. Design was a descriptive and correlational study. Simulated telephone speech and eight interfering noise types presented as continuous signals were linearly combined and were presented together either acoustically or magnetically to the participants' CIs. The participants could adjust the loudness of the telephone speech and the interfering noises based on several assigned criteria. The 21 test participants ranged in age from 23-81 yr. All used wireless phones with their CIs, and 15 also used cordless phones at home. There were 12 participants who normally used the telecoil mode for telephone communication, whereas 9 used the implant's microphone; all were tested accordingly. A guided-intake questionnaire yielded general background information for each participant. A custom-built test control box fed by prepared speech-and-noise files enabled the tester or test participant, as appropriate, to switch between the various test signals and to precisely control the speech-and-noise levels independently. The tester, but not the test participant, could read and record the selected levels. Subsequent analysis revealed the preferred speech levels, speech (signal)-to-noise ratios, and the effect of possible noise-measurement weighting functions. The participants' preferred telephone speech levels subjectively matched or were somewhat lower than the level that they heard from a 65 dB SPL wideband reference. The mean speech (signal)-to-noise ratio requirement for them to consider their telephone experience "acceptable for normal use" was 20 dB, very similar to the results for the hearing aid users of the previous study. Significant differences in the participants' apparent levels of noise tolerance among the noise types when the noise level was determined using A-weighting were eliminated when a CI-specific noise-measurement weighting was applied. The results for the CI users in terms of both preferred levels for wireless and cordless phone communication and signal-to-noise requirements closely paralleled the corresponding results for hearing aid users from the previous study, and showed no significant differences between the microphone and telecoil modes of use. Signal-to-noise requirements were directly related to the participants' noise audibility threshold and were independent of noise type when appropriate noise-measurement weighting was applied. Extending the investigation to include noncontinuous interfering noises and forms of radiofrequency interference other than additive audiofrequency noise could be areas of future study.

Hearing and hearing-impaired children's acoustic–phonetic adaptations to an interlocutor with a hearing impairment

In England, the majority of children with a hearing impairment attend mainstream schools. However, little is known about the communication strategies used by children when interacting with a peer with hearing loss. This study examined how children with normal-hearing (NH) and those with a hearing impairment (HI) adapt to the needs of a HI interlocutor, focusing on the acoustic–phonetic properties of their speech. Eighteen NH and 18 HI children between the ages of 9 and 15 years performed two problem-solving communicative tasks in pairs: one session was completed with a friend with normal hearing (NH-directed speech) and one session was done with a friend with a hearing impairment (HI-directed speech). As expected, task difficulty increased in interactions involving a HI interlocutor. HI speakers had a slower speech rate, higher speech intensity, and greater F0 range than NH speakers. However, both HI and NH participants decreased their speech rate, and increased their F0 range, mean F0 and the intensity of their speech in HI-directed speech compared to NH-directed speech. This suggests that both NH and HI children are able to adapt to the needs of their interlocutor, even though speech production is more effortful for HI children than their NH peers.

Loudness perception and speech intensity control in Parkinson's disease

The aim of this study was to examine loudness perception in individuals with hypophonia and Parkinson's disease. The participants included 17 individuals with hypophonia related to Parkinson's disease (PD) and 25 age-equivalent controls. The three loudness perception tasks included a magnitude estimation procedure involving a sentence spoken at 60, 65, 70, 75 and 80dB SPL, an imitation task involving a sentence spoken at 60, 65, 70, 75 and 80dB SPL, and a magnitude production procedure involving the production of a sentence at five different loudness levels (habitual, two and four times louder and two and four times quieter). The participants with PD produced a significantly different pattern and used a more restricted range than the controls in their perception of speech loudness, imitation of speech intensity, and self-generated estimates of speech loudness. The results support a speech loudness perception deficit in PD involving an abnormal perception of externally generated and self-generated speech intensity. Learning outcomesReaders will recognize that individuals with hypophonia related to Parkinson's disease may demonstrate a speech loudness perception deficit involving the abnormal perception of externally generated and self-generated speech intensity.

Preparing an E-learning-based Speech Therapy (EST) efficacy study: Identifying suitable outcome measures to detect within-subject changes of speech intelligibility in dysarthric speakers

We explored the suitability of perceptual and acoustic outcome measures to prepare E-learning based Speech Therapy (EST) efficacy tests regarding speech intelligibility in dysarthric speakers. Eight speakers with stroke (n = 3), Parkinson’s disease (n = 4) and traumatic brain injury (n = 1) participated in a 4 weeks EST trial. A repeated measures design was employed. Perceptual measures were (a) scale ratings for “ease of intelligibility” and “pleasantness” in continuous speech and (b) orthographic transcription scores of semantically unpredictable sentences. Acoustic measures were (c) “intensity during closure” (ΔIDC) in the occlusion phase of voiceless plosives, (d) changes in the vowel space of /a/, /e/ and /o/ and (e) the F0 variability in semantically unpredictable sentences. The only consistent finding concerned an increased (instead of the expected decreased) ΔIDC after EST, possibly caused by increased speech intensity without articulatory adjustments. The importance of suitable perceptual and acoustic measures for efficacy research is discussed.

Acoustic Parameters and Salivary IL-6 Levels in Overweight and Obese Teachers

Either obesity or vocal loading task leads to elevation of proinflammatory cytokines such as interleukin 6 (IL-6). However, it is unknown whether vocal parameters after vocal loading are correlated with body mass index (BMI) or IL-6. We hypothesize that vocal loading induces an elevation of acoustic parameters of voice and salivary IL-6 in overweight and obese people. A total of 33 schoolteachers without any self-reported voice alterations were invited to participate in this study. Participants were classified according to BMI into normal, overweight, and obese groups. The vocal loading task consisted of loud speech (60-90minutes) in their classroom. Salivary and voice samples were taken before and after vocal loading. Perceptual and self-reported voice alterations and objective voice analyses were investigated. The relative concentration of salivary IL-6 was estimated by a colorimetric assay. Obese teachers showed a significant elevation in fundamental frequency value after vocal loading. In addition, reduction in harmonics-to-noise ratio (HNR) was observed in teachers with normal weight after vocal loading but not in overweight or obese groups. No significant correlation was observed between BMI and any of the acoustic parameters analyzed or salivary IL-6 levels. Furthermore, teachers who were overweight showed a significant increase in the salivary IL-6 levels after vocal loading. Interestingly, salivary IL-6 levels were positively correlated with HNR value in the overweight group after vocal loading. Excessive body weight is related to alterations in fundamental frequency and HNR. In addition, HNR, but not BMI, is associated with salivary IL-6 levels in overweight teachers.

A Case of Bilateral Thalamic Infarct Misdiagnosed as Conversion Disorder

Introduction: Thalamic infarcts are rarely seen clinical situations. The most important causes are small vessel diseases and lacunar infarctions, arterio-arterial embolisms due to large artery diseases, emboli originating from the heart, and migrainous strokes. Patients might be misdiagnosed because of presenting similar symptoms that are detected in psychiatric disorders; this may lead to a delay in proper treatment. . Case Report: A 73-year-old female patient presented to the emergency service with dizziness, somnolence, and unwillingness to talk and was initially diagnosed with conversion disorder, consulting with the psychiatry unit. In the neurological examination, limited cooperation, bilateral pupillary expansion, and vertical gaze palsy were observed. In brain magnetic resonance imaging (MRI), a lesion flashing in the diffusion sequences with glowing ADC sequences and acute ischemic lesions compatible with bilateral paramedian thalamic vessel territory were detected; antiplatelet and low-molecular-weight heparin therapy was started. During follow-up, short-term and distant long-term memory problems emerged. At the end of the 1-month followup, gaze paresis and sleepiness partially improved. However, the memory problems and slowness of the overall behaviors did not change prominently. Conclusion: In cases with bilateral paramedian thalamic artery obstruction, persistent amnesia; perseveration; deficits in naming, speech intensity, and fluency; attention; slowness of the overall behaviors; somnolence; emotional changes; decreased motivation; and memory problems are common clinical features. Symptoms may completely improve in a minority of patients.

Aerodynamic Analysis Comparison of Speech Breathing at Two Vocal Loudness and Life Breathing in Normal Elderly Female: Comfortable and Louder Speech

Aerodynamic Analysis Comparison of Speech Breathing at Two Vocal Loudness and Life Breathing in Normal Elderly Female: Comfortable and Louder Speech

Impact of Clear, Loud, and Slow Speech on Scaled Intelligibility and Speech Severity in Parkinson's Disease and Multiple Sclerosis

The perceptual consequences of rate reduction, increased vocal intensity, and clear speech were studied in speakers with multiple sclerosis (MS), Parkinson's disease (PD), and healthy controls. Seventy-eight speakers read sentences in habitual, clear, loud, and slow conditions. Sentences were equated for peak amplitude and mixed with multitalker babble for presentation to listeners. Using a computerized visual analog scale, listeners judged intelligibility or speech severity as operationally defined in Sussman and Tjaden (2012). Loud and clear but not slow conditions improved intelligibility relative to the habitual condition. With the exception of the loud condition for the PD group, speech severity did not improve above habitual and was reduced relative to habitual in some instances. Intelligibility and speech severity were strongly related, but relationships for disordered speakers were weaker in clear and slow conditions versus habitual. Both clear and loud speech show promise for improving intelligibility and maintaining or improving speech severity in multitalker babble for speakers with mild dysarthria secondary to MS or PD, at least as these perceptual constructs were defined and measured in this study. Although scaled intelligibility and speech severity overlap, the metrics further appear to have some separate value in documenting treatment-related speech changes.