To determine whether singing can be used to differentiate cortical from subcortical lesions and indicate potential impairment in prosody, patients admitted to the Johns Hopkins Bayview Inpatient Neurology Service were administered a short battery of tasks to evaluate their singing, receptive prosody, and productive prosody. Patients with ischemic stroke were identified, consented, and tested at the bedside by the study team within 48 hours of stroke onset. Team members were undergraduate students, trained to administer the battery by a speech-language pathologist and evaluated to ensure accuracy and consistency with administration. A standard script was followed when explaining the study and tasks to each participant. Tasks were administered in the following order, prioritizing the singing assessment as the primary outcome of interest. The order of stimuli presented remained consistent across subjects. There was no time limit associated with any of the tasks, although testing was stopped if participants expressed that they were too fatigued to continue. Hearing was not formally assessed prior to administration; however, none of the participants had a history of significant hearing impairment.

Participants were asked to sing “Happy Birthday.” This song was chosen given its widespread familiarity and well-known tune and its utility in assessing recitation, melody, and rhythm of speech as part of the BDAE-III battery.[26] Though the use of words during song production were encouraged both to better orient the participant to the task given its familiarity and that the majority of participants were not aphasic, they were not required (humming or other vocalization was acceptable), as the focus was on the appropriate modulation of pitch. An iPhone 8 was placed 2 to 3 inches from the mouth of the participant and its recording program used to record the song for further analysis (below). Participants were consented by the study team to have their singing recorded and stored for later evaluation.

The emotion recognition task was designed to evaluate receptive prosody. Stimuli have been previously published and successfully used to evaluate for prosodic impairment.[27,28] A female speaker recorded 25 sentences composed of nonwords with the phonological and morphological features of English intact (eg, I nestered the flegs). This prevented participants from relying on the semantic content of the phrases rather than prosodic cues when selecting the emotion that best corresponded to the recording. Each audio file was uploaded onto a PowerPoint slide along with instructions to pick the emotion best describing the speaker's tone of voice with the printed multiple-choice options: surprised, happy, sad, angry, and afraid. The 5 emotion words were presented in the same order on each slide. The PowerPoint was presented on a laptop (MacBook Pro) with volume and brightness set to 100%. Sentences were presented in the same order each time for consistency. Participants were asked to make their choice either by articulating an answer or pointing to their desired choice on the laptop screen. In cases where they were unsure, they were encouraged to select an emotion before moving to the next slide. Responses were marked correct if the participant appropriately identified the emotion.

The emotion production task was designed to evaluate productive prosody. Participants were asked to read 24 semantically neutral sentences (eg, The man knocked on our front door) in a given emotional state (surprised, happy, sad, angry, afraid, or bored).[29] Sentences were displayed on PowerPoint slides below 1 of the emotions listed above. The stimuli were presented on a laptop set to 100% brightness in the same order for each participant. When reading each sentence aloud, participants were asked to emphasize the emotion they were attempting to convey. Successful production of emotion was evaluated at the time of testing by the study team, who had been previously evaluated on their ability to accurately determine correctness based on adherence to prosodic cues (eg, fast rate and high pitch for happy, slow rate and low pitch for sad).

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