INTRODUCTION

Friedreich ataxia, the most common hereditary ataxia with a global prevalence of 1 in 40,000 people¹, is a progressive and inherited neurodegenerative disease affecting multiple organs, caused by a systemic deficiency of the mitochondrial protein frataxin. It leads to disturbances in intracellular iron homeostasis and deficiencies in proteins containing iron-sulfur clusters, resulting in various clinical manifestations. The main symptoms include progressive ataxia, loss of tendon reflexes, difficulty in speech articulation, hypertrophic cardiomyopathy, diabetes, and skeletal abnormalities². Impairments in oral communication are prominent. Muscle control problems affect word articulation, resulting in imprecise and unintelligible speech and impacting quality of life. Therapies to improve communicative function should focus on phonatory stability, vocal frequency and intensity control, and methods to increase speech rate².

Currently, there are no specific treatments proven to be effective for these changes, but an early and comprehensive evaluation by specialized professionals is recommended³. It is important to highlight that research and development of specific treatments for communication changes in Friedreich ataxia are ongoing, and it is crucial to continue investigating new therapeutic approaches to improve these patients’ quality of life and communication³. Therefore, this case report aimed to describe and evaluate the effects of an oral communication training program on a journalism student presented with Friedreich ataxia.

CASE PRESENTATION

This case report followed the Brazilian National Health Council guidelines, starting after approval by the Research Ethics Committee of the Hospital Português/Real Sociedade Portuguesa de Beneficência, BA, Brazil, under evaluation report number 2.780.453 and protocol CAAE 87624618.0.0000.0041, and after obtaining consent from the coordinator of the Journalism program where the participant studied. The student agreed to participate in the study by signing an informed consent form.

The participant was a 23-year-old single white male, a digital influencer, a journalism student, and a full-time intern at a university radio station. He had weekly vocal demands in situations such as meetings, presentations, classes, courses, social and cultural events, and content production for his social media. Before being diagnosed with ataxia, he underwent speech-language-hearing therapy and attended a public speaking course to improve his oral communication skills, which he said were useful for his professional performance when speaking in public.

An experienced neurologist diagnosed it through genomic mapping recently, when the patient was 23 years old. This young man was the only member of his family diagnosed with ataxia. He reported scoliosis and underwent Global Postural Reeducation (GPR), but felt very uncomfortable due to his body imbalance, frequently tripping and bumping into objects. He experienced tremors when standing up and sitting down.

This student participated in eight 2-hour group sessions of the Expressiveness Development Program for Oral Communication⁴, together with other journalism students, moderated by speech-language-hearing professionals and students. The intervention aimed to improve oral communication in interactive groups, considering vocal psychodynamics and the relationship between form and content, sound and meaning. It included strategies such as reading aloud, linked speech with different emotions, and audiovisual materials to improve speech, communication, and vocal function^5-8.

Data were initially collected in the first session, including questionnaires on sociodemographic data, speech and voice self-assessment, text reading recorded for later auditory-perceptual evaluation, and acoustic analysis. The first session also covered the fundamental aspects of the program. From the second to the seventh session, the program was divided into three parts: 1) dialogic exposure and auditory stimulation to develop communicative perception; 2) vocal exercises and strategies for vocal preparation; and 3) exercises and strategies for linked speech with text reading to develop oral communication. In the final session, the main training topics were reviewed, and final data were collected using the same protocols.

The study used an instrument adapted from the Self-Assessment of Voice and Speech Skills in Various Communicative Contexts questionnaire⁹, applying only two specific questions: "How do you perceive your diction (speech) when speaking in public?" and "How do you perceive the sound of your voice when speaking in public?". The response options for these two questions were: "The same as always", "Better than usual", "Worse than usual", and "Variable, according to the situation". The protocol was adapted to focus on the main difficulties reported by the participant.

The speech samples were recorded in the soundproof radio studio where the participant worked, keeping the noise below 50 dB SPL, and using a 44,000-Hz sampling rate and a 16-bit depth, an Audio-Technica microphone, model AT2020, equipped with a Shock Mount SH-100 anti-puff filter. The participant remained seated during all recordings. He read the following informative text (in Portuguese): "Jarbas Barbosa, the new chairman of Anvisa, advocates changes in food packaging. The measure is necessary to facilitate the identification of products with high salt, sugar, or fat content. This information is essential to ensure that all consumers make an informed choice when purchasing"⁴. This text was chosen because its structure and phonetic complexity are like the material with which he usually works. The samples were edited using Audacity software, version 2.1.3, considering only the last sentence of the text for the auditory-perceptual evaluation, as it is a short sentence, suitable for this analysis¹⁰.

The judges assessed the content following a three-part auditory-perceptual evaluation protocol⁴. In Part I, the judge listened to two samples (Reading A and Reading B) and assigned scores from 0 to 10 for specific labels such as clear voice, clear diction, message credibility, and engagement with the listener. In Part II, each sample was evaluated for the grade of hoarseness, classified on a scale of 0 to 3 - like the GRBASI scale¹¹. In Part III, they analyzed vocal and speech characteristics such as frequency, intensity, speech rate, pauses, modulation, and emphasis, assigning a score from 0 to 2 for each item: 0 for “completely adequate” to the text, 1 for “partially adequate” to the text, and 2 for “inadequate.” Similar readings were analyzed homogeneously, while different ones were analyzed separately.

The judges were analyzed for interrater and interrater agreement with other speech samples, as described in previous studies^10,12. The multiple kappa test was used to evaluate the internal agreement between the judges - values ​​less than zero indicated insignificant agreement; from 0 to 0.2, weak agreement; from 0.21 to 0.4, reasonable agreement; from 0.41 to 0.6, moderate agreement; from 0.61 to 0.8, strong agreement; and from 0.81 to 1, almost perfect or perfect agreement¹³. Due to the low agreement between the judges, it was decided to consider only the judge's judgment with the highest internal coefficient, which in this case was k = 1. The statistical tests were conducted using RStudio software, version 3.6.3.

Acoustic measures were obtained from text readings using the free software Praat (version 6.4.07), developed by Paul Boersma and David Weenink, from the University of Amsterdam. Various measures were extracted, including mean, median, standard deviation, minimum, and maximum fundamental frequency (f0), as well as spectral decay (long-term-average spectrum [LTAS]), cepstral peak prominence (CPP), and cepstral peak prominence-smoothed (CPPS), speech duration, articulation and utterance rate, and loudness. The speech rate was calculated by annotating the words in the TextGrid layer and dividing the total number of words by the total audio time. Pauses were identified and annotated for articulation rate, subtracting the total pause time from the total audio time. The total number of words was then divided by the effective speech time in minutes/seconds¹⁴.

RESULTS

The participant's self-assessment of diction (speech) did not change after training, still being classified as "worse than usual". However, the self-assessment of the sound of the voice improved from "worse than usual" to "better than usual".

In the auditory-perceptual evaluation, the judge noted differences between the readings before and after the training. The reading score increased from 6 to 8, indicating an improvement in the quality of the reading. Moreover, the judge highlighted that diction had the most relevant change, and vocal quality progressed from "mild vocal deviation" before the training to "absence of vocal deviation" after the training. The vocal frequency and intensity in text reading changed from "partially adequate" to "adequate"; the speech rate changed from "inadequate" to "adequate"; pauses and emphasis changed from "inadequate" to "partially adequate"; and modulation remained "partially adequate" after the training.

F0 measures increased - the median changed from 210 Hz to 215 Hz; the mean f0, from 210 Hz to 220 Hz; the standard deviation, from 29 Hz to 35 Hz; the minimum f0, from 135 Hz to 142 Hz; and the maximum f0, from 269 Hz to 315 Hz. Spectral decay decreased from -19 to -14. CPP measures changed from 15.42 dB to 15 dB, and CPPs from 9.42 dB to 9.95 dB. Speech duration decreased from 7.22 seconds to 6.62 seconds. The articulation rate increased from 5.40 to 5.89 words per second, and the speech rate, from 2.35 to 2.56. There were also changes in vocal intensity, decreasing from 69.63 dB to 63.35 dB.

Lastly, the participant reported more public speaking experiences over the weeks after training, including situations such as meetings, presentations, lectures, conferences, courses, and social and cultural events. He found it easier to speak to many and few people alike and mentioned feeling less nervous than before training, experiencing nervousness only a few hours before speaking in public. However, he still feels nervous when he is unsure about the content and during presentations, lectures, meetings, classes, and public assessments. Anxiety when speaking in public caused sweating, gastrointestinal discomfort, and shortness of breath. He also reported voice tremors, vocal fatigue, and a higher-pitched voice than usual in these situations. The participant identified that he slows his speech down, switches phonemes, and becomes short of breath when speaking in public. Nevertheless, people generally rate his communication after the training as “excellent.”

DISCUSSION

This case report describes and evaluates the effects of an oral communication training program on a journalism student with Friedreich ataxia. This condition is characterized by symptoms such as progressive ataxia, loss of tendon reflexes, difficulty in speech articulation, tremors, imbalance, muscle weakness, and impaired motor coordination. These manifestations directly affect oral communication, compromising speech clarity, fluency, and coordination between breathing, articulation, and vocal production^1,2,15-18.

After the training, the participant reported a noticeable improvement in the quality of his voice and, most importantly, an increase in his self-confidence when communicating in public. This may be related to the reduction of specific communicative symptoms, such as vocal tremors, imprecise speech, and breathing and speech incoordination. Linked reading and vocal exercises helped improve the coordination between breathing, articulation, and vocal emission, reducing the incidence of inappropriate pauses and promoting more fluent speech in vocally healthy individuals^10,19 and those with progressive ataxia²⁰.

Reading aloud with different emotions and vocal modulation training, as suggested in the protocol, may have contributed to minimizing vocal tremors and improving speech f0 control. Studies indicate that precise articulation and phonatory control are constant challenges in individuals with Friedreich ataxia due to difficulties with motor coordination and stability^2,3. The program focused on strengthening these skills, which may have positively impacted the participant's vocal quality, as suggested by changes in perceptive assessments.

A study with ClearSpeechTogether²⁰ (an intervention method aimed at improving the speech of people with progressive ataxia) combined individual sessions and group practices focused on two main strategies: “LOUD” (effective and projected use of voice) and “CLEAR” (super articulation for greater clarity), practiced individually and in groups. It showed that interventions for people with progressive ataxia can improve speech intelligibility, increase confidence, and reduce vocal effort. The findings are relevant because they show that programs integrating strategies such as reading aloud and vocal modulation training contribute to phonatory control and articulation, which are often compromised in individuals with ataxia. The reduction in vocal effort suggests that the focus on modulation helps to stabilize vocal production, minimizing tremors and deviations in voice quality. In addition, participants reported feeling more confident and engaged, demonstrating greater control over their voice and a reduction in tremor symptoms. Reading practice with group feedback helped them internalize articulation and modulation strategies, improving performance in spontaneous and planned speech situations. Therefore, the study supports the idea that structured interventions, involving reading aloud with different emotions and vocal modulation training, can improve the quality and stability of speech in people with Friedreich ataxia.

Despite the small variations in f0 and vocal intensity (e.g., a 5 Hz increase in f0 and a 0.3 dB reduction in intensity), these results may indicate greater voice stability and better modulation control²¹. In individuals with Friedreich ataxia, inadequate vocal frequency control is associated with motor disorganization, resulting in monotonic speech and poor intelligibility^3,16. Thus, even small changes in these parameters can indicate progress in vocal stabilization.

The improved diction identified by the auditory-perceptual evaluation judge is especially relevant, considering that ataxic dysarthria is a common symptom in patients with Friedreich ataxia. This condition can result in slurred, hesitant speech with imprecise articulation³. The intervention program addressed these aspects through linked speech techniques, articulation exercises, and breathing practices, suggesting that the training may have contributed to clearer and more intelligible speech.

The participant reported that the anxiety to speak in public decreased during the study, which may reflect a positive effect of the training on self-perceived communication skills. Anxiety and nervousness can aggravate symptoms such as vocal tremors, shortness of breath, and muscle tension, often reported by individuals with this condition. By increasing confidence and assurance when speaking, the training may have helped to reduce vocal strain and failures associated with these emotional factors, thus improving communicative performance^12,22,23.

These results, although preliminary, suggest that interventions focused on developing oral communication in groups may help minimize some of the dysarthria symptoms associated with Friedreich ataxia. Furthermore, the psychodynamic approach integrating aspects of form, content, sound, and meaning may have promoted greater vocal self-perception and control. However, as the study is a case report, it is essential to replicate this intervention in a larger sample to validate these findings and measure its impact statistically.

In addition to using validated instruments to assess changes in confidence and self-esteem, future studies should correlate communication changes with motor and emotional parameters of patients with Friedreich ataxia. Additional investigations may also explore specific techniques that influence the reduction of symptoms such as tremors and vocal failures more directly.

CONCLUSION

The training program had positive results in the participant's oral communication, improving voice self-perception, vocal quality, diction, and some acoustic measures. These results, although consistent with the literature, should be considered preliminary, due to the nature of the study.

REFERENCES

Edited by

Data availability

Publication Dates

History