LANGUAGEASPECTS OF PATIENTS WITH MULTIPLE SCLEROSIS AliR?za SONKAYA, Zeynep Zeliha BAYAZIT AbstractMultipleSclerosis (MS) is one of the most common chronic disease among theneurodegeneretive disorders that kind of demyalinating disease of Central NervousSystem (CNS).

The clinical course of MS can be relapsing-remmitting orprogressive. The disease especially causes damage to myelin layers and alsoless of the axons. As a results of the damage some neurological impairments canbe seen, giving a symptomatology according to the forms of clinical phaseaffecting the motor, sensory, cerebellar, cognitive, language functions, etc. Sincebegining the identification of language functions abnormalities in MS, thelanguage performance evaluating provides the significant contribution tophysican in dignosis and follow-up of the MS patients. From this point of view,the present study aims to investigate the language aspects of MS fromlinguistic perspective.Keywords:Multiple sclerosis, language aspects, linguistic viewIntroductionMSis one of the most common neurodegeneretive chronic disease of CNS whichcharacterised by a variety of symptoms that result from demyelination andinflammation along axons in multiple regions in the brain and spinal cord (1,2).The disease affects women more than twice as much as men. The age of onsetranging is seen generally between 20 and 40 years (3).

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MS etiology is stillunknown but it is thought that MS is an autoimmune disease occurring in agenetically susceptible individual triggered by environmental factors (4,5,6). Althoughits course is unpredictable, clinical subgroups are identified. At clinicalonset, more than 85% of MS patients experience the exacerbation symptomsfollowed by periods when symptoms remit or disappear (3,5). This kind of form iscalled relapsing-remitting MS (RRMS). The other forms of MS are known primaryprogressive MS (PPMS) and secondary progressive MS (SPMS).  MS is influenced different areas in the brain, more particularly produceslesions throughout the white matter, resulting in a range of neurologicaldeficits, affecting the motor, sensory, cerebellar, cognitive,language functions, etc. Since begining the identification of languagefunctions abnormalities in MS, the language performance evaluating provides thesignificant contribution to physican in dignosis and follow-up of the MSpatients.

Languagedisorders in patients with MS can be sometimes disabling and they can manifestthemselves through motor speech aspects also known as dysarthria, respiratorydeficits, voice disorders like dysphonia, and high level of problems such ascomprehension and expression (7,8,9). Inclinical practices, generally health care professionals evaluate the languageaspects with naming and/or fluency tests (10) whereas linguistic theory suggestthat each facet of language be considered separately in order to come to a morethorough diagnosis because simple naming and fluency tests, though revealing,do not give a complete picture of language function (11). These tests may havefailed to identify more complex language processes. In the literature variosstudies have reported naming and fluency difficulties among the population ofMS (12,13). In addition, reduced speed of lexical access is another inconsistentlyreported linguistic deficit (14).

Morever, the majority of researches havereported competent reading, writing, and spelling feats as well as relativelyintact comprehension skills in patients with MS. Inconsistent findings amongresearchers make it difficult to draw tangible results about language aspectsin the population of MS.Itis conceivable that the assesment of the pragmatic dimension of languagecomprising the structural compenents of language which appears when language isused to communicate in a social context may draw a better frame for MS languageaspects than naming and fluency tests. Using common clinical measures toexamine pragmatic language ability in patients with MS might help to bettercharacterize the language aspects by this population and suggest insightregarding the conflictive findings produced by standardized testing. Thepragmatic use of language, has been less well studied in patients with MS(10,11), and how they are affected still remains poorly understood. For thisreason the present study aims to investigate the language aspects of MS anddetermine the language aspects derived from natural language samples throughthe linguistic perspective.MethodsParticipantsThis study was conducted on 35subjects (22 males + 13 females) of chronological age between 18 and 60 years.All subjects were diagnosed with RRMS according to 2010 McDonald criteria by aprofessional neurologist.

Participants with MS had no otherco-existing neurological disorder and had EDSS ? 3.5. The control group consisted of 35 subjects who matchedwith experimental group of the same age and sex. Patientswith MS were initially contacted by a neurology policlinic in order to protectpatient privacy rights. All participants were native speakers of Turkish. Theywere reported no history of speech therapy, no history of or current substanceabuse and also they were free from past or present use of antipsychoticmedication and did not use a hearing aid.

Prior to the experiment allparticipants were given an information about the research and taken to the studywho gave the consent. Data ProductionAllparticipants were instructed to talk for twenty minutes about their life andbackground to the neurologist. They were also explained that the neurologistwould only intervene if they became blocked. Thus, the pragmatic languageproductions were almost undirected with the participant having full freedom ofspeech. Whenever the participants stopped speaking for more than 5 seconds, theneurologist asked questions to encourage speech production in the participant.  Suchquestions were prefered open, instead of closed questions that can be answeredin a few words, so as to intervene as little as possible in the outputs of participants.In sum, the interference by the neurologist was as short as possible. Thisapproach allows greater opportunity to observe an individual’s communication(16)  and also it may be ensure determining theirlanguage aspects in clinical environment.

Theparticipants speechs were recorded using an digital voice recoder by theneurologist in a quite room. Sound recordings were transcribed by theresearhers.according to procedures outlined in Systematic Analysis of LanguageTranscripts (17) for subsequent analysis. Identification of language aspects wereobtained from the transcribed and recorded data from angle of phonology,morphology, sytax, semantic and pragmatic respectively (Table 1).                         Table   1. Description of LanguagePMeasures Linguistic system                       Deficits   Phonology Phonology is the study of the sound system of language, and includes the rules that govern its spoken form. Phonology analyzes which sound units are within a language and examines how these sounds are arranged, their systematic organization and rule system (18).

–         Frequently appear as articulation disorders. ·         Subject omits a consonant: “oo” for you ·         Subject substitutes one consonant: “wabbit” for rabbit ·         Discrimination: subject hears “go get the nail” instead of mail Morphology Morphology is the study of the structure of words; it analyzes how words are built out of morphemes, the basic unit of morphology. Morpheme is the smallest meaningful unit of a language (18) –         Subject may not use appropriate inflectional endings in their speech (e.

g.,”He walk” or “Mommy coat”). –         Subject may lack irregular past tense or irregular plurals (e.g., “drived” for “drove” or “mans” for “men”).

Be aware of “Black English”: “John cousin” “fifty cent”, or “She work here”. Syntax Syntax consists of organizational rules denoting word, phrase, and clause order. It also examines the organization and relationship between words, word classes, grammar of the language and other sentence elements (18) –         Lack the length or syntactic complexity (e.g., “Where Daddy go?”). –         Problems comprehending sentences that express relationship between direct or indirect objects.

Difficulty with wh questions. Difficulty with grammar of language (eg. ” mum went to work everyday) Semantic Semantic is the study of linguistic meaning and includes the meaning of words, phrases, and sentences (18).  –         Limited vocabulary especially in adjectives, adverbs, prepositions, or pronouns. –         Longer response time in selecting vocabulary words. –         Fail to perceive subtle changes in word meaning: incomplete understanding and misinterpretations. –         Figurative language problems.

Pragmatic Pragmatic is the study of knowledge and ability to use language functionally in social or interactive situations and integrates all the other language skills, but also requires knowledge and use of rule governing the use of language in social context.   –         Problems understanding indirect requests (e.g., may say yes when asked “Must you play the piano?”). –         May enter conversations in a socially unacceptable fashion or fail to take turns talking. –         Difficulty staying on topic.

 According to linguisticperspective phonology, morphology and syntax are constituted the forms oflanguage. Semantic states the content and pragmatic indicates the using oflanguage (Figure 1). Figure 1. Language Components and Skills  Data analysisThefirst step in the analyses was to create composite measures from SALT analyses.To examine the concordance language aspects between MS and healthy volunteer, linguisticmeasures were derived from the speech data. A Linguistic composite was createdby phonetic,morphologic,syntactic,semantic and pragmatic. Staticalanalysis were carried out in SPSS 18. Evaluation of descriptive datas were usedt-test and The Mann–Whitney U test was used to search for comparing patientswith MS and healthy controls.

p<0.05 was considered significant.ResultsThestudy was conducted on 35 (22 male+13 female) patients with MS and 35 (15male+20 female) healthy volunteers matched by sex, age and education. Patientswith MS group had a mean age of 32.50 years (sd = 8.47 years), and theirages ranged from 20 to 56 years; subjects in the control group had a mean ageof 28.15 years (sd = 12.

10 years), with ages ranging from 18 to 52years. The education level for patients with MS group was 12.6 years (sd =1.64 years), indicating that on average, subjects had minumum high schooldegree. The education level of MS patients group ranged from 9 to 18 years. Theeducation level for subjects in the control group was 10.41 years (sd =2.

04 years), indicating that on average, participants with healthy controlgroup had minumum high school degree. The education level of control groupsubjects ranged from 10 to 16 years. In neurological examination patients with MS disabilitywas measured with the expanded disability status scale (EDSS). The mean EDSSscore for the MS subjects were 2.87 (sd = 1.36) ranged from 2 to 3.5(Table 2).Table 2.

Demogrphicand Clinical Information of the Subjects                     MS group Control group     mean±sd minimum maximum mean±sd minimum maximum n 35 35 Sex (M/F) 22/13 15/20 Age 32.50±8.47 20 56 28.15±12.10 18 52 Education 12.

60±1.64 9 years 18 years 10.41±2.04 10 years 16 years EDSS 2.87±1.

36 2 3.5 –  Analysisof the patienst with MS and control groups for gender differences demonstrated nosignificant difference, as determined by a chi-square (?2) test of independence(p =0.51).  Independent-samples t-testsindicated that the MS and control group subjects were similar in age, (p =0.058), and did not differ with regard to years of education (p = 0.

063).Participantsdata used to generate the SALT composites. A Linguistic composite was createdby phonetic,morphologic,syntactic,semantic and pragmatic to determine thelanguage aspects of MS patients comparing the healthy subjects.

The datademonstrates an uneven spread of errors with most participants showing aslightly high number errors in phonetic (p=0.015) morphologic (p=0.37),syntactic (p=0.026) and pragmatic (p=0.030).

It was found no significantdifference phonetic(p=0.125) and semantic (p=0.745) error between MS andhealthy subjects (Table 3).    Table 3. SALT data analysis for patients with MS and ControlGroups. Variables MS group (mean±sd) Control Group (mean±sd) z p Phononetic error 74.

7 ± 44.52 41.61±10.87 -1.285 0.015 Morphologic error 140.42±2.68 84.

57±26.98 -0.143 0.

037 Syntactic erros 192.53±13.32 102.

28±7.46 -2.085 0.026 Semantic error 84.

65±35.78 54.85±4.26 -1.421 0.745 Pragmatic error 181.43±13.

32 142.28±7.66 -2,176 0,030  DiscussionThesystematic assessment of complex speech abnormalities in MS has previously beenlimited to perceptual tests (19). These tests may have failed to identify morecomplex language processes. It is thought that language comprising thestructural compenents of language which appears when language is used tocommunicate in a social context may draw a better frame for MS language aspects.From this point of view the present study was to examine language aspects in spontaneousspeech of patients with MS and compared to healthy controls.

Speech sampleswere recorded from MS patients and healthy controls after that they weretranscribed into SALT format. First speech samples were analysed for linguisticcomplexity using phonetic, morphologic,syntactic,semantic and pragmaticmeasures then MS and control groups were statically compared. Results fromspeech samples demonstrated the MS patients displayed linguistic errorsrelatively higer on every measure than the healthy subjects. All these differenceswere found statistically significant except semantic errors. Unlikethe majority of previous studies (10,11,20) our findings showed no statisticallysignificant differences between MS patients and healthy control on the semanticevaluation of speech samples, although patients with MS displayed semanticerrors slightly higher than the control participants. Recently, Ebrahimipour etal. (2017) did not find significant differences on their work which was carriedout 90 Parsian MS patients investigating semantic fluency (12).

Similarly,Potagas et al. (2009) did not find significant differences on a semantic wordlist generation task in Greek MS patients (21). Nevertheless, semantic fluency and word finding testshave also been shown to be influenced by oral motor slowing (10). Thediscrepancies in the literature regarding the presence or absence of semanticdeficits in patients with MS are probably attributable to a wide range ofmethodological differences involving sample selection and tests employed (22).Speechimpairment in patients with MS can be sometimes disabling and they can manifestthemselves through motor speech aspects also known as dysarthria, voicedisorders like dysphonia, several sound impairments (7,8,9).

Based ondysarthria MS patients can face to high level phonetic problems in daily life. The evaluation of dysarthria, by using a noninvasiveacoustic analysis of vocal signal can represent a valid clinical support to theotolaryngologist, neurologist and speech pathologist for early and differentialdiagnosis and for documenting the disease progression (23). Also in theliterature, clinical assessment of dysarthria in patients affected by MShave been studied and reported statistically significant differences withrespect to normal subjects (23,24). Rosen et al. (2008) researched the effects ofMS on speech production in their study and they examined the whether phoneticstructure is matter or not. They reported thedysarthria affects the production of extremely rapid changes in wovel formantsand that some phonetic structures are more useful than others for detectingthese impairments (25).

A study on expressive phonologywas carried out by Kujala (1996) demonstrated phonological deficit in patientswith MS (26). In paralel with previous studies (9,23,25,27) our findings showedMS patients displayed phonetic errors compared to control group alsodifferences were found statitically significant. In contrast to our study  Ivnik(1978) found no impairment with receptive phonology in MS (28). Likewise, Koeniget al.

(2008) did not find significant differences on their work which was investigatedphonological fluency and functionalconnectivity in MS used by clinical standardized test (29). The differencesbetween the findings of these researches and the our study may have occurredfor several reasons such as the severity levels of the participants, thelanguage data collection tasks, and the phonetic measurements applied to thedata.Itis known from the literature, MS patients have displayed syntactic failure (14,15)but measures of syntax show mixed evidence for impairment in MS. Grossman etal. (1995) examined the syntactic abilities of patients with MS using apicture-matching task designed by the authors. The stimuli were manipulated forgrammatical voice and presence and location of a relative clause. Authorsreported MS patients performed a significant predominance of gramatical and subject-objectreversal errors compared the controls (30). Smilarly to Grosmann et al.

(1995),our findings demonstrated MS patients displayed high level semantic errors whichkind of morpho-syntactic deficits, producing irregular plurals and ommitedmorphems compared to healthy group. Morphological component has an importantrole in syntactic phrase. Toan extent, it can conceivable that morphology sits at interface of syntax.Because of this relation between morphologic and syntactic components,morphologic errors directly affect the syntactic phrase. Also it cause to languagedeficits. Our results showed MS patients performed syntactic errors gernerallyarrising from morphologic errors in their spontanous speech.Languageproduction is a vital component of everyday social interaction andcommunication, and impairment of this capacity may lead to the inadequatetransmission of ideas and more frequent misunderstandings (10).

It has beenreported that MS patients could also experience de?cits in pragmatics, thecontext-dependent aspects of meaning beyond the structural components oflanguage (31). In line with the previous findings, our study results showed theMS patients performed pragmatic errors in their spontanous speech. We thinkthat pargmatic errors in MS majorly depends on cognitive impairment.

Likewise DeRenzi and Vignolo (1962) pointed out the cognitive impairment in their longitudinalstudy which demonstrated that patients with MS showed deterioration in languagecomprehension (32). Similarly Arrondo et al. (2009) showed  the pragmatic disability in MS patients and authors attributed the pragmaticdisability arising from  cognitiveimpairment.  Insummary, patients with MS have pragmatic and structural deficits in languageproduction, and these difficulties are related to cognitive impairment andexecutive dysfunction in particular, although the possibility that dysarthriamay be partly responsible for such differences cannot be disregarded (10). Inthis study we aimed to identify language aspects of MS from linguistic view. Weefforted to investigate structural and pragmatic components of language viaspontanous speech transcriptions using by SALT measurement.

This measurementscan ensure more contribute to clinicans compared to standartized tests  when they evaluating the  language performance in MS.Ourstudy has several limitations. The limited size of the sample might also haveprevented us from identifying the entirely language aspects of MS.

 Also detailed analysis of language aspectsusing by conversational or narrative speech measures may demonstrate otherdifferences between patients with MS and healthy subjects. Future studiesmay concentrate on the development of more sensitive testing measures bothformal and informal to identfy the language aspects of MS and the use of largersample sizes having a wider range of severity.