Literature_Review Final

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The Effects of Oral Motor Exercises on Diadochokinetic Rates

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Abstract

The effects of oral motor exercises (OMEs) on diadochokinetic (DDK) rates wereinvestigated. The participants consisted of 18 female students majoring inCommunicative Sciences and Disorders. Participants were randomly selected to engage

in the tongue press or blowing task. The DDK rates were measured before and afterimplementation of the OMEs. The researchers hypothesized that there will be nodifferences in the DDK rates before and after implementing the OMEs. The results fromthe blowing task revealed that 44% of the participants DDK rates increased, whereas thetongue press revealed that 67% of the participants DDK rates increased. There was nosignificant difference in the DDK rates before and after the implementation of OMEs.

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Table of Contents

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Chapter One

Introduction

During the screening of patients with suspected communication deficiencies, different

tools are used to assess current level of functioning and to determine which treatment

option best serves the problem. Diadochokinetic (DDK) rates are a technique that speech-

language pathologist (SLP) use in screenings. The major areas of emphasis in DDK rates

are tongue and lips. The lips and tongue play the most important role in articulation. Oral

motor exercises (OMEs) are used as assessment and treatment tools. OMEs and DDK are

separate entities, but the relationship between the two should be explored. In order to

explore this new concept, previous literature will be reviewed. Initially, OMEs and DDK

rates will be explained. Next, deficiencies within previous research will be examined.

Lastly, based on the findings from previous literature, practical implications will be made

to formulate a research question.

Oral motor exercises

Oral motor exercises (OMEs), also referred to as non-speech oral motor exercises

(NSOMEs), are movements of the articulatory structures that are used to strengthen the

structures. OMEs provide information about the strength of the articulatory structures

needed to produce specific speech sounds. OMEs can be defined as repetitive drills that

rely on conditioning the muscles of the mouth and face (Marshalla, 1999 as cited in

Cascella & Guisti Braislin, 2008). Oral movements of the jaw, tongue, and lip muscles

are used to stretch and strengthen the oral structures and improve intelligibility. Some

common technique are pursing lips, elevating the tongue, and blowing. They are often

used as treatment options. In the study conducted by Cascella and Guisti Braislin (2008),

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an oral motor therapy approach was used for children with mild articulation disorders.

The oral motor procedure implemented was Easy Does it for Articulation: An Oral

Motor Approach and was assessed over a seven week time period. Some techniques used

were pucker resistance, tongue tip elevation, tongue lateralization, and jaw resistance.

The results showed that the number of errors decreased after the use of oral motor

exercises as a treatment was implemented.

Diadochokinetic rates

An important part in the screening and assessment of oral motor skills is the

collection of diadochokinetic rates (DDK). DDK rates are an assessment tool used to

measure the rate an accuracy of oral movements. They allow speech-language

pathologists (SLPs) to identify how the articulators move in sequence to produce target

sounds, to detect abnormality, and to classify disorders (Gadesmann & Miller 2008).

DDK performance is broken down into three categories that include rate, accuracy, and

sequencing and consistency. Rate can be measured by counting the number of syllable

repetitions (consonant-vowel) articulated over a specified time period. Accuracy can be

determined by the number correct productions. Sequencing and consistency can be

determined by whether the patient maintains order of speech sounds within context

(Stackhouse & Williams, 2000).

DDK rates can also be used to determine the prognosis in individuals with speech

disturbances. A recent study of patients with dysarthria caused by severe

acceleration/deceleration head injuries showed that diadochokinetic rates were directly

related to the severity of the head trauma. Patients with severe the head trauma, produced

slower DDK abilities. Based on this information, researchers concluded that DDK rates

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can assist in rating the severity of dysarthria and provide some insight to prognosis

(Ergun & Oder, 2008). If prognosis is known then clinical decisions about assessment

and treatment can be made.

Deficiencies in Literature on Evidence Based Practice

Evidence- based practice (EBP) is an important aspect within the field of

communicative sciences and disorders. Systematic research allows the determination for

clinical diagnosis and treatment. EBP is the use of evidence to determine an appropriate

technique to be used for a specific population of patients with communicative disorders.

Oral motor exercises have been used in evidence-based practice to effectively treat

communicative disorders.

A few types of oral motor exercises with regards to the tongue have been found to

support the improvement of oral functioning and speech production within evidence-

based practice. For example, Molfenter, Steele, and Yeates (2008) examined the use of

lingual isometric strengthening exercises and tongue pressure accuracy tasks with

individuals from 50-72 years old. These individuals suffered from dysphagia as a

secondary cause to a stroke, traumatic brain injury (TBI), or a progressive disease.

Researchers found that an increase in isometric tongue strength and tongue pressure

generation accuracy significantly improved the oral phase of swallowing. With the use of

videofluoroscopy, the individuals were found to have better bolus control. Calleja, Clark,

Corrie, and OBrien (2009) analyzed the effects of lingual strengthening exercises on 39

healthy adults over a 9 week period of time. Their findings replicated previous studies

that demonstrated an increase in lingual strength and ability. They also confirmed that

after discontinuing the variety of exercise protocols, detraining effects were observed.

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Current research suggested that there is a lack of sufficient evidence to

support or refute the effects that OMEs have on speech (Frymark, Lof, McCauley,

Schooling, & Strand, 2009). Few articles have been published regarding the efficacy of

non speech oral motor activities and its effect on the improvement of speech production.

The articles that have been published in this area tend to focus on the effectiveness of

OMEs and additional treatment approaches. However, there are some findings that OMEs

are effective in improving speech production. A major dilemma in this topic of interest is

variability. Research that has been examined shows a wide range in age within the

participants of a given study. An evidenced-based systematic review (EBSR) ranged from

infants to the elderly population. Lack of sufficient evidence is found within participants

with a wide range and variety of medical diagnoses and disorders, and the types of the

OMEs used. All of these factors cause the potential for subjective bias. Integrity of a

clinician is also an important principle; reliability and non experimental approaches may

conclude to false positive results and insufficient evidence (Frymark, Lof, McCauley,

Schooling, & Strand, 2009).

Research has also been found that SLPs disregard evidence-based practice

even when statistics show OMEs to be beneficial to their clients. Lof & Watson (2008)

examined the number of SLPs who used non speech oral motor exercises with children

who displayed speech sound problems. SLPs that were certified by the American

Speech- Language-Hearing Association (ASHA) were surveyed. The researchers found

that 85% of the participants had implemented the use of non-speech oral motor exercises

(NSOMEs) into their treatment plans for at least one of their clients. Of the 85% of the

SLPs that implemented the use of NSOMEs, 92.7% had clients that benefited from this

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technique. However, 68% of those SLPs used NSOMEs as a last resort because other

techniques were not successful. Lof and Watson concluded that SLPs were going against

EBP by implementing inappropriate and unreliable treatments.

In a study conducted by Gadesmann and Miller (2008), the reliability of the DDK

rating system was examined. Their results found that the SLPs and the untrained

participants both measured abnormally low on the ability to rate diadochokinesis; the

SLPs reliability rate was lower than what is considered acceptable for clinical diagnosis

and assessment. The researchers concluded that the SLPs experience did not greatly

impact the results as expected. Experience should have been a factor in accurately

measuring diadochokinesis. Therefore, it is logical that untrained participants scored

similarly to trained SLPs.

Conclusion

Despite previous findings, research has also been found that refutes the

relationship between OMEs and oral functioning and speech production. Ruscello (2008)

examined the effects of non speech oral motor treatments (NSOMTs) with children that

displayed developmental speech sound disorders. NSOMTs are a collection of

nonspeech methods and procedures that claim to influence tongue, lip, and jawresting

postures; increase strength; improvemuscle tone; facilitate range of motion; and develop

muscle control (Ruscello, 2008, p.380). The use of NSOMTs were found to be

questionable because of the etiology of the disorder, the neurophysiologic variation of the

limbs and oral musculature, the advances in the theories of movement and movement

control, and the lack of research relating to NSOMTs. This study found no sufficient

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The reliability and consistency of OMEs and DDK rates are clearly faulted due to

violations of EBP, and lack of experience and knowledge. Although these two variables

have been researched independently, the relationship between OMEs and DDK rates has

not been explored. Thus, the aim of the current study is to identify which OMEs best

improve DDK rates. The null hypothesis for this study is that there will be no difference

in the DDK rates before and after implementing OMEs.

Rationale

Since previously overlooked in earlier studies, the research that will be

conducted in the current study will provide valid explanations to discern the relationship

between OMEs and DDK rates. The results and conclusions obtained from this research

study can be used to assist with the treatment of clients who display symptoms of

dysarthria, degenerative diseases, traumatic brain injuries (TBI), strokes, articulation

problems, and apraxia.

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Chapter Two

Design

Variables

The dependent variables are the diadochokinetic rates. Diadochokinetic rates are

an assessment tool used to measure the rate and accuracy of oral motor movements. The

rate can be measured by counting the number of syllable repetitions (consonant-vowel)

articulated over a five second time period. The independent variables are oral motor

exercises, the tongue press and blowing. The tongue press is a type of oral motor exercise

that strengthens ones tongue muscles by pushing against an immovable force. Blowing

is a type of exercise that strengthens ones lip muscles. To blow, one must fill their

cheeks with air, purse their lips, and release a sudden burst of exhalation.

Research Design

The current study will follow the A-B-A design. This design can be described as

factorial because it measures the effects two independent variables have on the dependent

variable. More specifically, this research design signifies that a pretest will be

administered to measure the participants present level of performance. Following this

stage, treatment will be implemented in an attempt to improve the dependent variable.

During the last stage, the posttest is administered to measure the effectiveness of the

treatment. This study is considered a qualitative design because there is little information

known about the relationship between the independent and dependent variables. The

study is also considered experimental because the variables will be experimentally

controlled.

Methods

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Participants

The participants for this study were 20 female students majoring in

Communicative Sciences and Disorders at Hampton University. The participants were

between the ages of 19 and 35. Participants with a history of hearing, speech, fluency, or

oral motor problems were excluded. A consent form was dispersed to each participant

prior to the study. Numbers were distributed to protect confidentiality.

Materials

Materials needed for this experiment included 2 sheets of paper, 1 baseball cap, 1

stop watch or timer, 20 tongue depressors, 1 ruler, tape, 20 straws, and 1 cotton ball.

Procedure

To ensure randomization, researchers divided the 2 sheets of paper into 20 pieces,

and the number 1 was placed on 10 segments of paper and the number 2 on the other 10.

The 20 pieces of paper were then placed in a baseball cap. Each participant reached into

the baseball cap to determine which oral motor exercise they were to perform. A ruler

was used to measure out 3 ft. on a table, and a piece of tape was placed to show the mark.

All measurements were collected on an individual level. In order to distinguish

between the participants, group 1 was assigned the tongue press and group 2 was

assigned a blowing task. These exercises were chosen because they were most cost

effective and explored two different oral structures. To begin, the researchers collected

pre-experimental diadochokinetic (DDK) rates from each participant. DDK rates were

measured by counting the frequency of syllable repetitions (consonant-vowel) articulated

over a five second interval. Participants in group number 1 articulated /t / repetitions for

five seconds, while the remaining participants in group 2 articulated /p / repetitions for

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five seconds. After these measurements were collected for pretest results, the members in

Group 1 were provided information about the tongue press exercise. The tongue press is a

type of exercise which strengthens your tongue muscles by pushing against an

immovable force. Group 1 stuck out their tongues and pressed against the tongue

depressor for 5 seconds. This task was repeated 4 additional times with 2 second rests

between repetitions. Immediately after the last repetition, DDK rates were collected by

having the participants articulate /t / repetitions for five seconds. The members in Group

2 were provided information about the blowing task. Blowing is a type of exercise that

strengthens ones lip muscles. For this exercise, each participant was given a straw and

instructed to blow a cotton ball to or past the 3 ft. mark. DDK rates were collected

immediately after blowing the cotton ball 3ft. by having the participants articulate /p /

repetitions for five seconds. Analysis was conducted to compare which oral motor

exercise improved DDK rates the most.

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Chapter Three

Results

The current study tested the null hypothesis that there will be no difference in the

DDK rates before and after implementing the oral motor exercises (OMEs). Data was

collected from 18 participants. To begin, the researchers collected pre-experimental

diadochokinetic (DDK) rates from each participant. DDK rates were measured by counting the

frequency of syllable repetitions (consonant-vowel) articulated over a five second interval.

Participants in group number 1 articulated /t / repetitions for five seconds, while the

remaining participants in group 2 articulated /p / repetitions for five seconds. After these

measurements were collected for pretest results, the members in Group 1 were provided

information about the tongue press exercise. The tongue press is a type of exercise which

strengthens your tongue muscles by pushing against an immovable force. Group 1 stuck out

their tongues and pressed against the tongue depressor for 5 seconds. This task was repeated 4

additional times with 2 second rests between repetitions. Immediately after the last repetition,

DDK rates were collected by having the participants articulate /t / repetitions for five

seconds. The members in Group 2 were provided information about the blowing task. Blowing

is a type of exercise that strengthens ones lip muscles. For this exercise, each participant was

given a straw and instructed to blow a cotton ball to or past the 3 ft. mark. DDK rates were

collected immediately after blowing the cotton ball 3ft. by having the participants

articulate /p / repetitions for five seconds. Analysis was conducted to compare which oral

motor exercise improved DDK rates the most.

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Tables 1 and 2 present the raw data for each independent variable

Table 1 scores on the Blowing TaskBlowing

TaskBefore After

31 33

29 27

29 26

28 29

29 26

31 27

23 2029 31

31 35

Table 2 Scores on the Tongue Press

Tongue

PressBefore After

32 30

27 34

25 2827 30

33 31

27 29

33 31

25 33

26 29

In Table 1, it can be seen that the results varied depending on the participant. The results

from the blowing task revealed that 4 out of 9 (44%) participants diadochokinetic (DDK) rates

increased after implementation of the oral motor exercise. However, the remaining 5 (56%)

participants DDK rates decreased after implementation of the oral motor exercise. In

comparison to Table 1, the results also varied for Table 2. It was revealed that 6 out of 9 (67%)

participants DDK rates increased after implementation of the tongue press. Conversely, the

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remaining 3 (33%) participants DDK rates decreased after implementation of the oral motor

exercise. Figure 1 and Figure 2 illustrate the raw data for the independent variables.

Figure 1 illustrates the raw data for the Blowing TaskBlowing Task

0

10

20

30

40

1 2 3 4 5 6 7 8 9

Participants

DDKRates

Before

After

Figure 2 illustrates the raw data for the Tongue Press

Tongue Press

0

10

20

30

40

1 2 3 4 5 6 7 8 9

Participants

DDKRates

Before

After

The data was analyzed using descriptive statistics. The results of the statistics follow.

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Table 3 Data Analysis for Blowing Task

Before AfterMean

28.88888889 Mean

28.22222222

Standard Error0.8240220

54 Standard Error1.4792807

73

Median 29 Median 27

Mode 29 Mode 27Standard

Deviation2.4720661

62Standard

Deviation4.4378423

19Sample

Variance6.1111111

11Sample

Variance19.694444

44

Kurtosis4.4861865

41 Kurtosis0.4801647

85

Skewness

-

1.87970424 Skewness

-

0.255845497

Range 8 Range 15

Minimum 23 Minimum 20

Maximum 31 Maximum 35

Sum 260 Sum 254

Count 9 Count 9

In Table 3, the data obtained before and after the administration of the blowing task was

analyzed using descriptive statistics. Before the oral motor exercise was administered, results

yielded a mean of 28.89, a median of 29, a mode of 29, the standard deviation of 2.47, and a

range of 8. Findings revealed the kurtosis to be 4.49, which indicated significant distribution (flat

kurtosis) between the scores. The skewness was -1.88, which revealed that a significant amount

of scores were clustered toward the maximum range. After the oral motor exercise was

administered, results yielded a mean of 28.22, a median of 27, a mode of 27, the standard

deviations of 4.44, and a range of 15. Findings revealed the kurtosis to 0.48, which indicated a

normal distribution of the scores. The skewness was -0.26, which revealed that a significant

amount of scores were clustered toward the maximum range.

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Table 4 Data Analysis for Tongue Press

Before

After

Mean 28.33333333 Mean 30.55555556

Standard Error1.1180339

89 Standard Error0.6478835

44

Median 27 Median 30

Mode 27 Mode 30Standard

Deviation3.3541019

66Standard

Deviation1.9436506

32Sample

Variance 11.25Sample

Variance3.7777777

78

Kurtosis

-1.57601

4109 Kurtosis

-0.23412

0119

Skewness0.6757894

33 Skewness0.6804098

28

Range 8 Range 6

Minimum 25 Minimum 28

Maximum 33 Maximum 34

Sum 255 Sum 275

Count 9 Count 9

In Table 4, the data obtained before and after the administration of the tongue press was

analyzed using descriptive statistics. Before the oral motor exercise was administered, results

yielded a mean of 28.33, a median of 27, a mode of 27, the standard deviation of 3.35, and a

range of 8. Findings revealed the kurtosis to be -1.58, which indicated that the distribution was

within normal limits. The skewness was 0.68, which revealed that a significant amount of scores

were clustered toward the minimum range. After the oral motor exercise was administered,

results yielded a mean of 30.56, a median of 30, a mode of 30, the standard deviations of 1.94,

and a range of 6. Findings revealed the kurtosis to -0.23, which indicated that the distribution

was within normal limits. The skewness was 0.68, which revealed that a significant amount of

scores were clustered toward the minimum range.

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The data was analyzed using inferential statistics. The results of the statistics follow.

Table 5 Summary of data

SUMMARY

Groups Count Sum Average Variance

DDK Rates Before Blowing 9 260 28.88888889 6.111111111

DDK Rates After Blowing 9 254 28.22222222 19.69444444

DDK Rates Before Tongue Press 9 255 28.33333333 11.25

DDK Rates After Tongue Press 9 275 30.55555556 3.777777778

ANOVA

Source of Variation SS df MS F P-value F crit

Between Groups 31.33333333 3 10.44444444 1.023129252 0.395367297 2.9011195

Within Groups 326.6666667 32 10.20833333

Total 358 35

The inferential analysis of the data revealed a degree of freedom (df) of 3, an F-value

of 1.02, a P-value of 0.4, and a F-critical of 2.9. According to the F-value and P-value, the

results revealed no significant difference; therefore, the null hypothesis is accepted. In

conclusion, there was no difference in the DDK rates before and after the implementation of

the OMEs.

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Chapter Four

Discussion

In the current study, findings do not support that oral motor exercises (OMEs) improve

diadochokinetic (DDK) rates. The results do not contain enough variation to contribute to the

independent variable, OMEs. The findings, the possible reasons for the results obtained, and the

implications for clinical practice and further research will be discussed.

Regarding the blowing task, 4 out of the 9 participants DDK rates increased, and the

remaining 5 DDK rates decreased. For the tongue press, 6 out of the 9 participants DDK rates

increased, and the remaining 3 DDK rates decreased. Although differences were evident in the

raw data, they were not significant enough to contribute to the OMEs.

The findings support the previous literature (Frymark et al., 2009; Gadesmann & Miller,

2008; Lof & Watson, 2008; Ruscello, 2008) that indicates that OMEs do not improve speech.

However, other literature (Molfenter et al., 2008; Calleja et al., 2009) found OMEs to be

effective in improving swallowing.

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References

Ergun, A. & Oder, W. (2008). Oral diadochokinesis and velocity of narrative speech: A

prognostic parameter for the outcome of diffuse axonal injury in severe headtrauma. Brain Injury, 22, 773-779.

Calleja, A., Clark, H.M., Corrie, S.N., & OBrien, K. (2009). Effects of directional exerciseon lingual strength. Journal of Speech, Language, and Hearing Research, 52,1034-1047.

Cascella, P.W. & Guisti Braislin, M.A. (2005). A preliminary investigation of the efficacy oforal motor exercises for children with mild articulation disorders. International Journalof Rehabilitation Research, 28, 263-266.

Fletcher, S.G. (1972). Time-by-Count Measurement of Diadochokinetic Syllable Rate. Journalof Speech and Hearing Research, 15, 763-770.

Frymark, T., Lof, G.L., McCauley, R.J., Schooling, T., & Strand, E. (2009). Evidence-basedsystematic review: effects on non speech oral motor exercises on speech. AmericanJournal of Speech-Language Pathology, 18, 343-360.

Gradesmann, M., & Miller, N. (2008). Reliability of speech diadochokinetic test measurement.International Journal of Language & Communication Disorders, 43(1), 41-54.

Lof, G., & Watson, M. (2008). A nationwide survey of non speech oral motor exerciseuse: Implications for evidence-based practice. Language, Speech, and Hearing Servicesin Schools, 39,392-407.

Molfenter, S.M., Steele, C.M., & Yeates, E.M. (2008). Improvements in tongue strength andpressure-generation precision following a tongue-pressure training protocol in olderindividuals with dysphagia: three case reports. Clinical Interventions in Aging, 3(4), 735-747

Ruscello, D.M. (2008). Non speech oral motor treatment issues related to children withdevelopmental speech sound disorders. Language, Speech, Hearing Services inSchools, 39,380-391.

Stackhouse, J. & Williams, P. (2000). Rate, accuracy and consistency: diadochokineticperformance of young normally developing children. Clinical Linguistics & Phonetics,14(4), 267-293.

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Appendix A

Informational Consent Form

SPEECH, LANGUAGE AND HEARING CLINICHAMPTON UNIVERSITYHAMPTON, VA

CONSENT FORM

To participants:

You will be participating in a research study that examines how tongue and lip exercises affecthow well you can produce sounds. This study will take about 15 minutes of your time. 16 participants are

needed to conduct this experiment. You will be divided into two groups based on drawing a number, 1 or2, from a hat. You will also be given a number from 1-16 for identification purposes; therefore, nopersonal information will be collected. After you are in your respective group, a researcher will ask you toproduce a specific sound, which will be modeled for you first. This task will not cause you any pain ordiscomfort. After each person has completed this task, you will take part in the experimental portion ofthe study.

If you are in Group 1 you will be asked to perform a tongue press exercise. The tongue press is atype of exercise which strengthens your tongue muscles by pushing against an immovable force. If youare in Group 2, you will be asked to perform a blowing task. Blowing is a type of exercise thatstrengthens your lip muscles. After you have completed one of these tasks, a researcher will ask you toproduce a specific sound again, which will be modeled for you first. These tasks will cause minimal or nodiscomfort.

Your participation is voluntary; refusal will involve no penalty or loss of benefits to which youare otherwise entitled. You may discontinue at any time without penalty or loss of benefits to which youare otherwise entitled. This study will not put you at any risk or to your embryo or fetus if you were tobecome pregnant. Your participation may be terminated by the researcher without the regard to yourconsent. If you are terminated from the study, the researcher will inform and explain why. The cost to youis $0.00. You will not receive any compensation for your participation in this study. You will beinformed of any significant findings that are discovered within this study. You have the right to obtain acopy of the consent form. This consent form is only valid if it has been signed by the chair of theHampton University IRB. You have the right to contact Dr. Robert Forbes, the chairperson of the IRB, at(757) 727-5419 with any questions pertaining to this study, as well as your rights.

Please check the following box if you smoke cigarettes

Please check the following box if you have asthma

_______________________________ ______________________________(Participants Name Printed) (Participants Signature & Date)

_______________________________ ______________________________(Chairpersons Name Printed) (Chairpersons Signature)

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Appendix B

Data Collection

Diadochokinetic (DDK) rates can be referred to as an assessment tool, used by speech-language pathologists (SLPs), that measures how quickly an individual can accurately produce aseries of rapid, alternating sounds (Fletcher, 1972).

Instruments

The instruments used in this study included SuperDuper tongue depressors, straws, cottonballs, tape measurer, tape, RCA audio recorder (Model Number VR5220-A), stopwatch from aSamsung Behold cellular device, 18 sheets of paper, and two highlighters.

Scoring Procedure

DDK rates were measured by a trained researcher by counting the frequency of syllablerepetitions (consonant-vowel) articulated. The Samsung Behold stopwatch was used toaccurately calculate each five second interval. The trained researcher would tally the number ofrepetitions by using a highlighter to mark a sheet of paper with a tally mark. The RCA audiorecorder was used to ensure intrajudge reliability.

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