R?za SONKAYA, Zeynep Zeliha BAYAZIT

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Sclerosis (MS) is one of the most common chronic disease among the
neurodegeneretive disorders that kind of demyalinating disease of Central Nervous
System (CNS). The clinical course of MS can be relapsing-remmitting or
progressive. The disease especially causes damage to myelin layers and also
less of the axons. As a results of the damage some neurological impairments can
be seen, giving a symptomatology according to the forms of clinical phase
affecting the motor, sensory, cerebellar, cognitive, language functions, etc. Since
begining the identification of language functions abnormalities in MS, the
language performance evaluating provides the significant contribution to
physican 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 from
linguistic perspective.

Multiple sclerosis, language aspects, linguistic view


is one of the most common neurodegeneretive chronic disease of CNS which
characterised by a variety of symptoms that result from demyelination and
inflammation 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 onset
ranging is seen generally between 20 and 40 years (3). MS etiology is still
unknown but it is thought that MS is an autoimmune disease occurring in a
genetically susceptible individual triggered by environmental factors (4,5,6). Although
its course is unpredictable, clinical subgroups are identified. At clinical
onset, more than 85% of MS patients experience the exacerbation symptoms
followed by periods when symptoms remit or disappear (3,5). This kind of form is
called relapsing-remitting MS (RRMS). The other forms of MS are known primary
progressive MS (PPMS) and secondary progressive MS (SPMS).  

MS is influenced different areas in the brain, more particularly produces
lesions throughout the white matter, resulting in a range of neurological
deficits, affecting the motor, sensory, cerebellar, cognitive,
language functions, etc. Since begining the identification of language
functions abnormalities in MS, the language performance evaluating provides the
significant contribution to physican in dignosis and follow-up of the MS

disorders in patients with MS can be sometimes disabling and they can manifest
themselves through motor speech aspects also known as dysarthria, respiratory
deficits, voice disorders like dysphonia, and high level of problems such as
comprehension and expression (7,8,9). In
clinical practices, generally health care professionals evaluate the language
aspects with naming and/or fluency tests (10) whereas linguistic theory suggest
that each facet of language be considered separately in order to come to a more
thorough diagnosis because simple naming and fluency tests, though revealing,
do not give a complete picture of language function (11). These tests may have
failed to identify more complex language processes. In the literature varios
studies have reported naming and fluency difficulties among the population of
MS (12,13). In addition, reduced speed of lexical access is another inconsistently
reported linguistic deficit (14). Morever, the majority of researches have
reported competent reading, writing, and spelling feats as well as relatively
intact comprehension skills in patients with MS. Inconsistent findings among
researchers make it difficult to draw tangible results about language aspects
in the population of MS.

is conceivable that the assesment of the pragmatic dimension of language
comprising the structural compenents of language which appears when language is
used to communicate in a social context may draw a better frame for MS language
aspects than naming and fluency tests. Using common clinical measures to
examine pragmatic language ability in patients with MS might help to better
characterize the language aspects by this population and suggest insight
regarding the conflictive findings produced by standardized testing. The
pragmatic use of language, has been less well studied in patients with MS
(10,11), and how they are affected still remains poorly understood. For this
reason the present study aims to investigate the language aspects of MS and
determine the language aspects derived from natural language samples through
the linguistic perspective.



This study was conducted on 35
subjects (22 males + 13 females) of chronological age between 18 and 60 years.
All subjects were diagnosed with RRMS according to 2010 McDonald criteria by a
professional neurologist. Participants with MS had no other
co-existing neurological disorder and had EDSS ? 3.5. The control group consisted of 35 subjects who matched
with experimental group of the same age and sex. Patients
with MS were initially contacted by a neurology policlinic in order to protect
patient privacy rights. All participants were native speakers of Turkish. They
were reported no history of speech therapy, no history of or current substance
abuse and also they were free from past or present use of antipsychotic
medication and did not use a hearing aid. Prior to the experiment all
participants were given an information about the research and taken to the study
who gave the consent.

 Data Production

participants were instructed to talk for twenty minutes about their life and
background to the neurologist. They were also explained that the neurologist
would only intervene if they became blocked. Thus, the pragmatic language
productions were almost undirected with the participant having full freedom of
speech. Whenever the participants stopped speaking for more than 5 seconds, the
neurologist asked questions to encourage speech production in the participant.  Such
questions were prefered open, instead of closed questions that can be answered
in 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. This
approach allows greater opportunity to observe an individual’s communication(16)  and also it may be ensure determining their
language aspects in clinical environment.

participants speechs were recorded using an digital voice recoder by the
neurologist in a quite room. Sound recordings were transcribed by the
researhers.according to procedures outlined in Systematic Analysis of Language
Transcripts (17) for subsequent analysis. Identification of language aspects were
obtained from the transcribed and recorded data from angle of phonology,
morphology, sytax, semantic and pragmatic respectively (Table 1).





                    Table   1. Description of Language

Linguistic system



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


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”.


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?”).
comprehending sentences that express relationship between direct or indirect
Difficulty with wh questions.
Difficulty with
grammar of language (eg. ” mum went to
work everyday)


is the study of linguistic meaning and includes the meaning of words,
phrases, and sentences (18). 

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
language problems.


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

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
staying on topic.


According to linguistic
perspective phonology, morphology and syntax are constituted the forms of
language. Semantic states the content and pragmatic indicates the using of
language (Figure 1).


Figure 1. Language Components and Skills


Data analysis

first step in the analyses was to create composite measures from SALT analyses.
To examine the concordance language aspects between MS and healthy volunteer, linguistic
measures were derived from the speech data. A Linguistic composite was created
by phonetic,morphologic,syntactic,semantic and pragmatic.

analysis were carried out in SPSS 18. Evaluation of descriptive datas were used
t-test and The Mann–Whitney U test was used to search for comparing patients
with MS and healthy controls. p
<0.05 was considered significant. Results The study was conducted on 35 (22 male+13 female) patients with MS and 35 (15 male+20 female) healthy volunteers matched by sex, age and education. Patients with MS group had a mean age of 32.50 years (sd = 8.47 years), and their ages ranged from 20 to 56 years; subjects in the control group had a mean age of 28.15 years (sd = 12.10 years), with ages ranging from 18 to 52 years. The education level for patients with MS group was 12.6 years (sd = 1.64 years), indicating that on average, subjects had minumum high school degree. The education level of MS patients group ranged from 9 to 18 years. The education level for subjects in the control group was 10.41 years (sd = 2.04 years), indicating that on average, participants with healthy control group had minumum high school degree. The education level of control group subjects ranged from 10 to 16 years.  In neurological examination patients with MS disability was measured with the expanded disability status scale (EDSS). The mean EDSS score for the MS subjects were 2.87 (sd = 1.36) ranged from 2 to 3.5 (Table 2). Table 2. Demogrphic and 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 -   Analysis of the patienst with MS and control groups for gender differences demonstrated no significant difference, as determined by a chi-square (?2) test of independence (p =0.51).  Independent-samples t-tests indicated 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). Participants data used to generate the SALT composites. A Linguistic composite was created by phonetic,morphologic,syntactic,semantic and pragmatic to determine the language aspects of MS patients comparing the healthy subjects. The data demonstrates an uneven spread of errors with most participants showing a slightly 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 significant difference phonetic(p=0.125) and semantic (p=0.745) error between MS and healthy subjects (Table 3).         Table 3. SALT data analysis for patients with MS and Control Groups. 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   Discussion The systematic assessment of complex speech abnormalities in MS has previously been limited to perceptual tests (19). These tests may have failed to identify more complex language processes. It is thought that language comprising the structural compenents of language which appears when language is used to communicate 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 spontaneous speech of patients with MS and compared to healthy controls. Speech samples were recorded from MS patients and healthy controls after that they were transcribed into SALT format. First speech samples were analysed for linguistic complexity using phonetic, morphologic,syntactic,semantic and pragmatic measures then MS and control groups were statically compared. Results from speech samples demonstrated the MS patients displayed linguistic errors relatively higer on every measure than the healthy subjects. All these differences were found statistically significant except semantic errors. Unlike the majority of previous studies (10,11,20) our findings showed no statistically significant differences between MS patients and healthy control on the semantic evaluation of speech samples, although patients with MS displayed semantic errors slightly higher than the control participants. Recently, Ebrahimipour et al. (2017) did not find significant differences on their work which was carried out 90 Parsian MS patients investigating semantic fluency (12). Similarly, Potagas et al. (2009) did not find significant differences on a semantic word list generation task in Greek MS patients (21). Nevertheless, semantic fluency and word finding tests have also been shown to be influenced by oral motor slowing (10). The discrepancies in the literature regarding the presence or absence of semantic deficits in patients with MS are probably attributable to a wide range of methodological differences involving sample selection and tests employed (22). Speech impairment in patients with MS can be sometimes disabling and they can manifest themselves through motor speech aspects also known as dysarthria, voice disorders like dysphonia, several sound impairments (7,8,9). Based on dysarthria MS patients can face to high level phonetic problems in daily life. The evaluation of dysarthria, by using a noninvasive acoustic analysis of vocal signal can represent a valid clinical support to the otolaryngologist, neurologist and speech pathologist for early and differential diagnosis and for documenting the disease progression (23). Also in the literature, clinical assessment of dysarthria in patients affected by MS have been studied and reported statistically significant differences with respect to normal subjects (23,24). Rosen et al. (2008) researched the effects of MS on speech production in their study and they examined the whether phonetic structure is matter or not. They reported the dysarthria affects the production of extremely rapid changes in wovel formants and that some phonetic structures are more useful than others for detecting these impairments (25). A study on expressive phonology was carried out by Kujala (1996) demonstrated phonological deficit in patients with MS (26). In paralel with previous studies (9,23,25,27) our findings showed MS patients displayed phonetic errors compared to control group also differences were found statitically significant. In contrast to our study  Ivnik (1978) found no impairment with receptive phonology in MS (28). Likewise, Koenig et al. (2008) did not find significant differences on their work which was investigated phonological fluency and functional connectivity in MS used by clinical standardized test (29). The differences between the findings of these researches and the our study may have occurred for several reasons such as the severity levels of the participants, the language data collection tasks, and the phonetic measurements applied to the data. It is known from the literature, MS patients have displayed syntactic failure (14,15) but measures of syntax show mixed evidence for impairment in MS. Grossman et al. (1995) examined the syntactic abilities of patients with MS using a picture-matching task designed by the authors. The stimuli were manipulated for grammatical voice and presence and location of a relative clause. Authors reported MS patients performed a significant predominance of gramatical and subject-object reversal errors compared the controls (30). Smilarly to Grosmann et al.(1995), our findings demonstrated MS patients displayed high level semantic errors which kind of morpho-syntactic deficits, producing irregular plurals and ommited morphems compared to healthy group. Morphological component has an important role in syntactic phrase. To an 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 language deficits. Our results showed MS patients performed syntactic errors gernerally arrising from morphologic errors in their spontanous speech. Language production is a vital component of everyday social interaction and communication, and impairment of this capacity may lead to the inadequate transmission of ideas and more frequent misunderstandings (10). It has been reported that MS patients could also experience de?cits in pragmatics, the context-dependent aspects of meaning beyond the structural components of language (31). In line with the previous findings, our study results showed the MS patients performed pragmatic errors in their spontanous speech. We think that pargmatic errors in MS majorly depends on cognitive impairment. Likewise De Renzi and Vignolo (1962) pointed out the cognitive impairment in their longitudinal study which demonstrated that patients with MS showed deterioration in language comprehension (32). Similarly Arrondo et al. (2009) showed  the  pragmatic disability in MS patients and authors attributed the pragmatic disability arising from  cognitive impairment.   In summary, patients with MS have pragmatic and structural deficits in language production, and these difficulties are related to cognitive impairment and executive dysfunction in particular, although the possibility that dysarthria may be partly responsible for such differences cannot be disregarded (10). In this study we aimed to identify language aspects of MS from linguistic view. We efforted to investigate structural and pragmatic components of language via spontanous speech transcriptions using by SALT measurement.This measurements can ensure more contribute to clinicans compared to standartized tests  when they evaluating the  language performance in MS. Our study has several limitations. The limited size of the sample might also have prevented us from identifying the entirely language aspects of MS.  Also detailed analysis of language aspects using by conversational or narrative speech measures may demonstrate other differences between patients with MS and healthy subjects. Future studies may concentrate on the development of more sensitive testing measures both formal and informal to identfy the language aspects of MS and the use of larger sample sizes having a wider range of severity.