Defining “Stimulability” for Voice-Specialized Speech Language Pathologists: A Scoping Review

Defining “Stimulability” for Voice-Specialized Speech Language Pathologists: A Scoping Review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Defining “Stimulability” for Voice-Specialized Speech Language Pathologists: A Scoping Review View ORCID Profile Elizabeth D. Young doi: https://doi.org/10.1101/2025.10.23.25338650 Elizabeth D. Young 1 School of Behavioral and Brain Sciences, University of Texas at Dallas , Richardson, TX Ph.D., CCC-SLP Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Elizabeth D. Young For correspondence: elizabeth.young{at}utdallas.edu Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Purpose Speech-language pathologists have used the term “stimulability” since at least the 1950s ( Milisen, 1954 ). However, the term is used in multiple ways in the current literature, and authors frequently do not make the distinction between stimulability testing (i.e., the procedure) and stimulability level (i.e., the results of the procedure). This paper presents a narrative overview of the history of stimulability testing in voice disorders, proposes a new standard definition for stimulability testing, and provides a scoping review of the terminology, definitions, behavioral targets, and types of measurement scales used to describe stimulability testing and stimulability level in the current literature. Methods A literature search was conducted in PubMed, EBSCOhost, and Google Scholar for peer-reviewed articles containing the terms “stimulability” or “stimulable”. Articles including information regarding the behavioral assessment of patients with voice disorders were included. Results 93 articles were included in the review. Only 23% of articles provided an adequate definition of stimulability testing or stimulability level; over half (51%) mentioned search terminology in passing without any further definition or description, and the remaining quarter (26%) described stimulability testing or level rather than providing a formal definition. The term “stimulability” in isolation was used to refer to stimulability testing in 13% of instances and stimulability level in 51% of instances. Conclusion Stimulability testing and stimulability level are infrequently defined and poorly differentiated from each other in the current literature. Given the clinical importance of stimulability testing, increased care is needed in future work to be specific and precise with terminology. Introduction The first use of the term “stimulability” is generally attributed to Milisen (1954) within the context of assessment for children with speech sound disorders. Milisen (1954) described it as “the stimulation of the child with a [verbal, visual, and kinematic model of a speech sound], and his imitation of it” (p. 9). Thus, in its original context, stimulability testing was an assessment of a child’s ability to imitate a speech sound with a model. Stimulability testing for children with speech-sound disorders has been the subject of a modest amount of research, particularly in the 1990s (e.g., Lof, 1996 ; Tyler, 1996 ; Miccio et al., 1999 ; interested readers are directed to Glaspey, 2012 , for an excellent narrative review of this literature). In the early 1970s, stimulability testing began to be adopted into other areas of speech-language pathology, particularly voice disorders. Many consider Daniel Boone’s “voice therapy facilitating techniques”, first introduced in his 1971 textbook ( Boone, 1971 ) as the basis of stimulability testing in voice disorders. Boone originally described these techniques as “prob[ing] continually within the patient’s existing vocal repertoire to find that one voice which sounds ‘good’ and which he is able to produce with relatively little effort” ( Boone, 1971 , p. 109; nearly identical definitions are provided in subsequent versions of the textbook). Recent surveys of practicing voice-specialized speech-language pathologists found that 93% of respondents completed stimulability testing “always” or “almost always” with their patients, and 97% of respondents found it “important” or “very important” to their practice ( Toles & Young, 2023 ). Similarly, 94% of surveyed laryngologists reported stimulability testing is performed “Always” or “Sometimes” in their practice, and 100% reported there is a benefit to using it when working with patients with voice disorders (Coleman et al., in press). Thus, what began as a practice in speech-sound disorders has become extremely prevalent and highly valued for practicing voice-specialized speech-language pathologists and others involved in the care of the voice. Stimulability, Stimulability Testing, and Stimulability Level Despite the prevalence of stimulability testing in many areas of speech-language pathology, the term “stimulability” is used inconsistently in the literature (and, in the author’s experience, in clinical practice). Recall that Milisen (1954) used the term “stimulability” to describe an assessment. In 1996, a widely cited review conducted by Powell and Miccio stated that Milisen (1954) also described the results of their stimulability testing using the term “stimulability” – if a child’s imitated productions were more accurate than their spontaneous productions of a speech sound, that child was said to have “good stimulability”. This was, in actuality, a misattribution – Milisen (1954) used the term “stimulable” to refer to the results of stimulability testing – but the damage was done, and the use of the term “stimulability” to refer to both a procedure (i.e., a stimulability test) and the results (a child with good or poor stimulability) became commonplace. The tendency to use “stimulability” as a catch all term for both as an assessment procedure and the results of such a procedure continues to the present day. As one example of this, Petty et al. (2023) recently provided the following definition of stimulability: “Stimulability is the assessment of an individual’s ability to modify a behavior when provided with models or cues. Positive stimulability during evaluation is predictive of treatment success in voice therapy.” (p.3). Note that at the beginning of this quote, Petty et al. (2023) state that stimulability is an assessment, but later within the same paragraph used the term “positive stimulability”, thus implying that stimulability is the result of an assessment. As noted above, Milisen (1954) originally introduced the term “stimulable” to refer to the results of stimulability testing, and this term remains frequent in the literature (i.e., a person could be either “stimulable” or “not stimulable”; e.g., Sund et al., 2021 .) However, it also remains common to see the term “stimulability” along with “stimulable” in reference to the results of stimulability testing (e.g., Gartner-Schmidt & Gillespie, 2021 ; Free et al., 2022 ). To the author’s knowledge, only one attempt has been made to address the ambiguity of terminology in recent work. Turner and Toles (2025) define “stimulability” as “an individual’s ability to change a behavior when prompted with cues and supports” (p. 1); in other words, the result of an assessment. These authors differentiate stimulability from stimulability testing by defining stimulability testing as “the assessment of an individual’s ability to change their behavior in the presence of cues and supports” (p. 1). While Turner and Toles do indeed provide much needed clarity with the use of these distinctions, the continued use of “stimulability” without descriptive modifiers has the potential to lead to continued conflation of the terms as it has in the past. Thus, for improved clarity and precision, the author will utilize the terms “stimulability testing” to refer to the assessment procedure, and “stimulability level” to refer to the results of such a procedure. Given that “stimulable” has, in the author’s experience, uniformly been used to refer to stimulability level in the literature, this term will continue to be used in the review as it arises; however, stimulability level will be the preferred term given its increased precision. Stimulability level, as the result of stimulability testing, is used to help clinicians draw conclusions about the various functions of stimulability testing. Stimulability testing serves a variety of functions in the hands of a skilled clinician, ranging from diagnostic (e.g., differential diagnosis), to therapeutic (e.g., therapeutic planning, candidacy determination, improving patient “buy-in”), to prognostic (e.g., determining patient prognosis for behavioral therapy; Toles & Young, 2023 ; Young, 2025 ). A clinician can use stimulability level to inform each of these functions. For example, a patient who is “stimulable” may be a candidate for behavioral therapy, whereas a patient who is “not stimulable” may be a more suitable candidate for medical intervention. Thus, stimulability testing (the procedure) leads to stimulability level (e.g., “stimulable”), which allows a clinician to make informed decisions regarding the various functions of stimulability testing (e.g., “the patient is a candidate for behavioral therapy”). Defining Stimulability Testing Recent survey-based research suggests stimulability testing is utilized by over 90% of voice-specialized speech-language pathologists during their behavioral voice evaluation ( Toles & Young, 2023 ). However, there is no published work establishing a formalized definition of stimulability testing within either the speech sound disorders literature or the voice disorders literature. In both literatures, authors have been left to their own devices to determine what constitutes “stimulability testing”. This has resulted in discrepancies within existing definitions; for instance, Boone (1971) described stimulability testing as “probing continually… to find that one voice which sounds good” (p. 109), suggesting a rather lengthy process, while McDowell et al. (2023) defines it as the assessment of a person’s ability to make “ immediate changes to their voice” (p. 1, emphasis added), suggesting a much more rapid process. Despite this, there is sufficient consensus within the literature and among practicing clinicians to set forth a standardized definition of stimulability testing. Per Milisen’s original definition (“the stimulation of the child with a [verbal, visual and kinesthetic model of a speech sound], and his imitation of it”), stimulability testing involved determining a child’s ability to imitate a speech sound after being given a model. If one strips away the terminology specific to speech-sound disorders, Milisen’s (1954) definition of stimulability testing is assessing the extent to which therapeutic facilitators can modify an individual’s behaviors towards the normal or expected pattern. This is strikingly similar to the fundamental elements of the definition of stimulability testing provided by voice-specialized speech-language pathologists in recent peer-reviewed journal articles (e.g., “the evaluation of an individual’s ability to modify a behavior when provided with models or cues”; Gillespie and Gartner-Schmidt, 2016 , p. 507.e15; “observation of the person’s ability to modify the voice to direction” Payten et al., 2024 ; “the assessment of an individual’s ability to change their behavior in the presence of cues and supports” Turner & Toles, 2025 ; p. 1). Perhaps more importantly, 95% of practicing, voice-specialized speech-language pathologists provided definitions containing similar elements when asked to provide their definition of stimulability testing ( Toles & Young, 2023 ). Based on the above definitions, there is sufficient evidence to suggest three required “core” elements for a standardized definition of stimulability testing. First, the definition must describe stimulability testing as an assessment procedure (i.e., a procedure resulting in an outcome measure that will vary between individuals depending on their performance). The inclusion of this core element is needed to not only differentiate stimulability testing from stimulability level, but also to differentiate stimulability testing from interventions which use similar therapeutic techniques (i.e., stimulability testing involving clear speech is not the same as using Conversation Training Therapy as a behavioral intervention). Second, the definition must describe a procedure that is centered on modifying a behavior, typically towards what is considered “normal”. This element is required to specify that stimulability testing is a dynamic assessment (i.e., an assessment of change in behaviors), setting it apart from other static assessment procedures performed during a standard behavioral voice evaluation (e.g., videostroboscopy). Finally, definitions of stimulability testing should specify the use of therapeutic techniques or facilitators, such as modeling, cueing, or use of a specific voice facilitator (e.g., semi-occluded vocal tract techniques). This element adds specificity to the definition that implies the involvement of skilled therapeutic intervention. Patient voice symptomatology may change for a variety of factors outside of therapeutic control (e.g., amount of voice use, hormonal changes, seasonal allergies, emotional state, etc.). Thus, it is critical that the role of a skilled interventionist as the active agent of behavioral change be outlined in the definition of stimulability testing. Based on the above, the proposed standardized definition of stimulability testing is “the assessment of an individual’s ability to change or modify a behavior, typically towards ‘normal’, utilizing therapeutic techniques or facilitators”. While this definition does include the three core elements noted above, note that it does not specify which behaviors that are being modified, nor the timeline in which modification must occur. These factors could feasibly be specified in a definition of stimulability testing, there is, as of yet, no strong evidence to suggest they must be included within a standardized definition. One purpose of this study is to determine whether this proposed definition, including the three proposed core elements above, is supported by current literature, as well as examine other elements of a standardized definition that could be included in the future. Determining Stimulability Level Similar to stimulability testing, stimulability level has been variably described in the literature. As previously described, one facet of this stems from the variable terminology used to describe stimulability level (i.e., “stimulability” vs “stimulable”). Stimulability level is further defined by two components – the behavioral target which is being measured (e.g., forward resonance) and the type of measurement scale being used to measure this target (e.g., binary vs. categorical). Both components have been described in a variety of ways in the literature. The behavioral targets of stimulability testing, and thus those being evaluated for change with stimulability level, have varied since the establishment of stimulability testing in the speech sound disorders literature. In this literature, many authors described stimulability level as both an individual-specific measure (i.e., a child’s overall ability to correct speech-sound errors when provided with examiner stimulation; Goldman et al., 2015; Lof, 1996 ; Miccio et al., 1999 ). Meanwhile, other authors referred to stimulability level as behavior-specific measurement – in this case, specific phonemes – where, for example, a child could be stimulable for /k/ but not stimulable for /s/ (e.g., Glaspey, 2012 ; Powell & Miccio, 1996 ). These two different behavioral targets for stimulability level have extended into the voice disorders literature, and examples of both individual-specific (e.g., “stimulability for behavioral treatment”, Lewandowski et al., 2018 , p. 909) and behavior-specific (e.g., “stimulability to increased loudness”, Constantinescu et al., 2011 , p. 3) targets are commonplace. Measurement scale types used to specify stimulability level are also far from standardized. Stimulability level was originally described as a binary measurement of whether an imitated production of a speech sound was more accurate (i.e., closer to the expected version of the speech sound) compared to the spontaneous production ( Milisen, 1954 ; Powell & Miccio, 1996 ). Children who were able to produce the speech sound more accurately during stimulability testing were said to have “good stimulability” ( Powell & Miccio, 1996 ). Many voice-specialized speech-language pathologists use a similar binary method of measuring stimulability level (e.g., Gillespie & Gartner-Schmidt, 2016 use “Good stimulability”) or using other binaries (e.g., “stimulable” vs “not stimulable”; Litts et al., 2015; “positive” vs “negative”; Petty et al., 2023 ). Other measurement scales for stimulability level also exist, including categorical scales (e.g., “excellent”, “good”, “poor”; Payten et al., 2022 ) and continuous scales (e.g., 100-mm visual analog scales; Young, 2025 ). The majority of practicing clinicians surveyed by Toles & Young (2023) reported using a categorical scale (67%), followed by a binary scale (23%). Further complicating the use of measurement scale types, however, is a lack of consensus on how frequently improvement must be observed and at what level in the speech hierarchy when measuring stimulability level. For instance, Tyler (1996) classified a speech sound as “stimulable” if it was produced correctly at least once at any level and over multiple opportunities. Rvachew et al. (1999) , on the other hand, used a scale from zero to three, where zero equaled stimulable (in all contexts) and three equaled “stimulable at the sentence level on presentation of a model for imitation” (p. 35). The Current Study Recent survey-based research indicates that both voice-specialized speech-language pathologists and laryngologists around the world perform stimulability testing frequently and value it as a clinical assessment tool (Coleman et al., in press; Payten et al., 2024 ; Toles & Young, 2023 ). However, there is currently no standard definition of stimulability testing or stimulability level, and it is unclear how closely existing studies align with the proposed definition of stimulability testing. Additionally, there is limited agreement on the terminology of both stimulability testing and stimulability level, including the use of terminology that conflates these two distinct elements. Finally, there is variability in the behavioral targets for stimulability testing and stimulability level, as well as the measurement scale types used for stimulability level. There has yet to be a systematic evaluation of these factors of stimulability testing and stimulability level in the voice disorders literature. To address this gap, the current study has the following aims: Compile and summarize the definitions of stimulability testing and stimulability level in the current peer-reviewed literature regarding voice disorders, and evaluate the definitions of stimulability testing against the proposed standard definition. Compile and summarize the terminology used to refer to stimulability testing and stimulability level in current peer-reviewed literature regarding voice disorders. Compile and summarize the behavioral targets of stimulability testing and stimulability level and types of measurement scales used for stimulability level in current peer-reviewed literature regarding voice disorders. Methods Literature Search A literature search was conducted on July 24 th , 2025 in three search engines; PubMed, EBSCOhost, and Google Scholar. The following search terms were used in PubMed and EBSCOhost: “ (voice OR dysphon*) AND stimulab*”. The following search string was used for Google Scholar, with the option to search within citing articles turned off: “ voice OR dysphonia OR dysphonic OR vocal OR stimulable “stimulability” –phonological –child” . The following inclusion criteria were used to assess the results. a) Only resources published in the English language available to the author to review were included. b) Only peer-reviewed articles were included; book chapters, conference proceedings/abstracts, and unpublished theses and dissertations were excluded. c) Only studies referencing stimulability testing or stimulability level in the context of voice disorders (including hypokinetic dysarthria, Parkinson’s disease or Parkinsonism, or treatments specific to these disorders) were included. Studies referencing stimulability testing in the contexts of speech sound disorders, upper airway disorders, resonance disorders specific to structural changes (i.e., cleft lip and/or palate), hearing disorders, aphasia, or dysarthria that was not specific to Parkinsonism, were excluded. d) Only articles that used the terms “stimulability” or “stimulable” within the article text were included. Further, these terms had to be used to refer to behavioral measures; articles that referred to physiologic measures of nerve conductance (e.g., “electrophysiologic stimulability”) were excluded. In addition to the formal literature review conducted here, articles from the author’s own informal literature examination over the past two years were also included. Inclusion criteria for these articles were identical the above, except that she did not limit herself to the exact use of the terms “stimulability” or “stimulable”. Instead, if the author encountered an article that described what she would consider stimulability testing, this article was included in the literature review. These articles are marked within the results tables using asterisks. Data Extraction For each article, the author extracted definitions, terminology, and behavioral targets used to describe stimulability testing. If a definition for stimulability testing was presented, the author determined whether the three core concepts of the stimulability testing definition presented in this paper were present or absent: (1) an assessment procedure, (2) focus on modifying a behavior, typically towards what is considered “normal,” (3) the utilization of therapeutic techniques or facilitators, such as modeling and cueing. The author likewise extracted the terminology, definitions, behavioral targets, and types of measurement scales used to describe stimulability level for each article. Results The literature search process is illustrated in Figure 1 . A total of 569 records were found in the initial literature search. After removal of duplicates from the three databases, 541 unique records remained. Titles were screened for relevance to the inclusion criteria listed in the methods section; 396 articles were removed during this stage, leaving 145 articles for full-text examination. Forty articles were removed for further consideration as they used the terms “stimulability” or “stimulable” to refer to a physiologic measure of nerve conductance. Eleven articles were removed because there was no mention of the terms “stimulability” or “stimulable” in-text. Four articles were removed from consideration as they were either not published in English (n = 3) or not accessible for review (n = 1). Two more articles were removed after full-text read throughs, as one mentioned the term “stimulability” only as a direct quote from another article that was previously included, and another was the transcription of a lecture delivered at a conference and was therefore not peer-reviewed despite being published in a peer-reviewed journal. The remaining 88 articles were included in the analysis. The author’s own independent reading of the literature resulted in the inclusion of an additional five unique articles; four that did not use the term “stimulability” or “stimulable” but that described what the author considered to be a comparable process based on the definition provided in the introduction, and one that used the term “stimulability” but was not captured in the formal literature search. Thus, the final analysis was conducted on 93 articles, which are displayed in Table 1 . Download figure Open in new tab Figure 1. Illustration of search strategy and selection of studies. View this table: View inline View popup Table 1. Articles included in the literature review. Classification of Results It became apparent during data extraction that many articles did not include enough detail regarding stimulability testing and stimulability level to extract the information outlined in the methods section. Many articles contained no definition or even description of either stimulability testing or stimulability level, making the extraction of information regarding definitions, behavioral targets, or measurement scale types impossible. Because of this, articles were classified based on the level of detail provided when discussing stimulability testing or stimulability level in-text. These classifications are displayed the rightmost column of Table 1 and summarized in Table 2 . View this table: View inline View popup Download powerpoint Table 2. Summary of Article Classifications Within Tables 1 and 2 , the classification “Mentioned Only, without a Definition” refers to articles which used search terminology in isolation, without further description or definition of the terminology itself. For example, the only use of the search terms in Helou (2017) is the following sentence: “Further, a good voice therapist pulls tricks out of their sleeve, seeking moments of stimulability until something works and sticks.” (p. 86, emphasis added). This was the most common classification of analyzed articles; over half (51%) of included articles fell into this category. The second classification was “Described rather than defined”; this classification was used when a clinical description of what was occurring during either stimulability testing or determination of stimulability level was provided rather than a higher-level definition of the essential qualities of stimulability testing or level. An example of this occurred on page 1934 of Sullivan et al., (2024) : “stimulability testing was conducted during the initial evaluation by instructing the participants to repeat speech tasks using intent following a clinician model.” Over a quarter (27%) of articles fell into this category. Articles that provided definitions of either stimulability testing or stimulability level were classified as “Definition provided”, and were further classified on whether they provided a definition for stimulability testing alone (15%), stimulability level alone (1%), or both stimulability testing and level (6%). Regardless of article classification type, the use of search terms within each article was analyzed to determine whether the authors were discussing stimulability testing or stimulability level. Of the included articles, 37 (40%) discussed stimulability testing only, while 24 (26%) discussed stimulability level only. Thirty-one articles (33%) discussed both stimulability testing and stimulability level. There was one instance where the use of the search terms was ambiguous to the point where it was indeterminate whether the term “stimulability” referred to stimulability testing or stimulability level: “For other clients the process of individualized prescription of yoga (including ‘ stimulability’ , the use of self-generated internal imagery, and on-going monitoring of responses) ensured that yoga practices were modified until a state of ‘flow’ could be achieved.” ( Moore, 2012 , p 146-147, emphasis added). Stimulability Testing Twenty of the 93 included articles (21.5%) provided definitions of stimulability testing, which are displayed in Table 3 . Table 3 additionally outlines whether each definition mentions each of the three core elements of the proposed standard definition of stimulability testing described in the introduction, as well as the target behavior described within the definition. Five (25%) of the twenty definitions do not mention one of the three core elements of the definition ( Countryman et al., 1997 ; Grill, 2021; McDowell et al., 2023 ; Toles et al., 2024 ; Weston et al., 2023 ), but all definitions mentioned at least two of the three core elements. All definitions mentioned modifying behavior; three definitions did not mention the use of therapeutic techniques ( Countryman et al., 1997 ; McDowell et al., 2023 ; Weston et al., 2023 ), and two did not mention variability between participants ( Grillo, 2021 ; Toles et al., 2024 ). The most frequent target behavior mentioned in the definitions is “Voice” or something similar ( Behrman, 2005 ; Dejonckere & Lebacq, 2001 ; Gillespie, 2022 ; Grillo, 2021 , Hartley et al., 2017 ; McDowell et al., 2023 ; Peyten et al., 2024; Schneider, 2019 ; Toles & Harris, 2023 ; Toles & Young, 2023 , Toles et al., 2024 ; Weston et al., 2023 ), but 30% of definitions mention only an unspecified “behavior” as the target ( Gartner-Schmidt & Gillespie, 2021 ; Gillespie & Gartner-Schmidt, 2016 ; Litts et al., 2015; Petty et al., 2023 ; Shelley et al., 2023; Turner & Toles, 2025 ). View this table: View inline View popup Table 3. Definitions of Stimulability Testing Provided by Articles within Literature Search The terminology used to refer to stimulability testing is displayed in Table 4 . Across the sixty-eight articles that discussed stimulability testing in this review, thirty different terms were used to describe this assessment process. “Stimulability testing” was the most used term, with just under 30% of articles including this term within the article text. “Stimulability assessment” also appeared relatively frequently, appearing in 10% of articles. However, “stimulability” in isolation (i.e., without a subsequent modifier, such as “testing” or “assessment”) appeared in 13% of articles, making it the second-most common term. The majority (71%) of articles used only a single term to refer to stimulability testing, while 16% used two terms ( Allensworth et al., 2019 ; Andreassen et al., 2017 ; Buckley et al., 2023 ; Free et al., 2022 ; Gartner-Schmidt & Rosen, 2009 ; Grillo, 2021 ; Litts et al., 2015; Shelly et al., 2023 ; Sund et al., 2021 ; Toles & Young, 2023 ; Turner & Toles, 2025 ), and 13% used three or more terms ( Adessa, 2021 ; Barson et al., 2023 ; Gartner-Schmidt & Gillespie, 2021 ; Helou et al., 2021 ; McDowell et al., 2023 ; Petty et al., 2023 ; Peyton et al., 2024; Schneider, 2019 ; Shembel et al., 2021 ), with a maximum of five different terms to refer to stimulability testing ( Helou et al., 2021 ). View this table: View inline View popup Table 4 – Terminology used to Refer to Stimulability Testing Across Articles Stimulability Level Table 5 displays the seven included articles which provided a definition of stimulability level, as well as the targets and measurement scales that could be extracted from these definitions. The specificity of the target behavior(s) described in each definition was quite variable; Dejonckere & Lebacq (2001) used nearly an entire page of their manuscript to outline the various measures used to capture their version of stimulability level (dubbed the “Index of Vocal Plasticity”, or IVP). In contrast, three of the seven definitions (43%) specified only a “behavior” or “cued task” as the target measured with stimulability level ( Gillespie & Gartner-Schmidt, 2016 ; Schneider, 2019 ; Shelley et al., 2019). In terms of types of measurement scales used, three definitions (60%) suggested the use of a binary measurement scale ( Gillespie & Gartner-Schmidt, 2016 ; McDowell et al., 2023 ; Shelley et al., 2023) and two provided a categorical scale (Dejonckere & Lebackq, 2001; Turner & Toles, 2025 ). The measurement scale could not be extracted from the remaining two definitions ( Gates, Knowles, Mach, Higginbotham, & Holder, 2024 ; Schneider, 2019 ). View this table: View inline View popup Table 5 – Definitions of Stimulability Level Provided by Articles within Literature Search Terminology used to refer to stimulability level is summarized in Table 6 . The term “stimulability” alone was used without additional modifiers to refer to stimulability level in the majority (51%) of articles. The second most frequent term used across articles was “stimulable”, although this term was variability presented as a positive binary only (“stimulable”; e.g., Van Leer et al., 2021 ), as a negative binary only (“not stimulable”; e.g., Watts et al., 2019 ;), or as both a positive and negative binary (“stimulable” and “not stimulable”; e.g., Weston et al., 2023 ). Eighteen additional terms were used to refer to stimulability level. Of these 18 terms, only one was used across more than one article; however, all articles that used this terminology were from the same author group (“level of stimulability”, utilized by McDowell, [Toles], et al., 2023; Toles et al. 2024 , and Turner & Toles, 2025). Thirty-seven articles (67%) used only a single term to describe stimulability level; twenty-six of these articles only used the term “stimulability” to refer to stimulability level (47% of total articles; 68% of articles using only a single term). Eighteen articles (33%) used two or more terms to describe stimulability level; the maximum number of terms used to describe stimulability level was eight (Turner & Toles, 2024). View this table: View inline View popup Table 6. Terminology used to Refer to Stimulability Level Across Articles Table 7 outlines the target behaviors extracted for stimulability level across thirty-three articles (excluding targets extracted from stimulability level definitions provided in Table 5 ). Of note, stimulability level was discussed in 55 articles, meaning the behavioral target of stimulability testing (i.e., what would be expected to change and could therefore be measured with stimulability level) was only extractable in 60% of relevant articles. Targets in Table 7 were classified as behavior-specific (either facilitators, such as “resonant voice”; De Almeida et al., 2019 ; or general behaviors, such as “improved voice quality”; Heller Murray et al., 2016 ) or individual-specific (e.g., “behavioral treatment”; Lewandowski et al., 2018 ). Fifteen articles (45%) specified a facilitator as the target for stimulability level, with five (15%) describing a general facilitator and ten (30%) describing a specific facilitator. Eleven articles (33%) described a broader behavior target, while four articles (12%) described an individual-specific target (all of which were generally candidacy-based; Bonilha & Dawson, 2012 ; Chen et al., 2020 ; Grillo & Wolfbert, 2023; Lewandowski et al., 2018 ). Three articles (9%) described targets from multiple categories ( Free et al., 2022 ; Gates, Knowles, Mach, & Higginbotham, 2024 ; McDowell et al., 2023 ). View this table: View inline View popup Table 7. Stimulability Level Target(s) and Classifications The types of measurement scales used for stimulability level were extractable from the text in 27 of the 55 articles discussing stimulability level (49%) and are displayed in Table 8 . Based on the terminology used in each of these articles to describe stimulability level, the type of measurement scale utilized was classified as either binary (e.g., “stimulable vs not stimulable”, Toles et al., 2024 ), categorical (e.g., “Excellent, good, poor”; Payten et al., 2022 ), or “multiple” if more than one measurement scale type was used. Twenty-one articles (78%) used a measurement scale that was classified as binary, and four articles (15%) used a categorical measurement scale ( Dejonckere & Lebacq, 2001 ; Peyten et al., 2022; Turner & Toles, 2025 ; Van Stan, Roy, et al., 2024). Two articles (7%) used multiple measurement scales ( Becker et al., 2025 ; McDowell et al., 2023 ) View this table: View inline View popup Table 8. Stimulability Level Measurement Scale Classification. Discussion Stimulability testing has a rich history as an assessment tool for speech-language pathologists specializing in many different areas, including voice disorders. However, this history has resulted in the blurring of terminology and subsequent imprecision of the descriptions used for this procedure. Thus, the current scoping review examined the definitions, terminology, and behavioral targets described for stimulability testing (i.e., the assessment procedure), as well those described for stimulability level (i.e., the results of said assessment procedure) in peer-reviewed literature focusing on voice disorders. Definitions of Stimulability Testing and Stimulability Level The first aim of this review was to compile and review the definitions of stimulability testing and stimulability level provided in the voice disorders literature. The majority of articles included in this review (77%) did not formally define either stimulability testing or stimulability level. In many articles, terms such as “stimulability” or “stimulable” were utilized without any definition or description, implying that these terms are understood to have a common definition among the articles’ readership. However, as described in the introduction and further outlined in Tables 3 and 5 , there is no common, consensus definition of stimulability testing nor stimulability level in the speech-language pathology literature. As a result, many articles provided definitions of either stimulability testing or stimulability level that were closer to descriptions of procedure than definitions. Of the 93 articles reviewed, only twenty (22%) provided a definition of stimulability testing. As part of the first aim of the study, each definition of stimulability testing was evaluated based on whether it contained the three core elements of a definition of stimulability testing as proposed in the introduction, namely that it must describe (1) an assessment procedure, (2) a focus on modifying a behavior, and (3) the utilization therapeutic techniques or facilitators, such as modeling and cueing. 75% of the evaluated definitions provided all three core elements of the proposed standardized definition of stimulability testing. Overall, this provides strong evidence that the proposed core elements are generally supported by the existing literature regarding stimulability testing. All twenty articles that defined stimulability testing described the second core element (i.e., modifying behaviors), suggesting that this is the central defining feature of stimulability testing in the current literature and solidifying this element as a required feature of a standardized definition of stimulability testing. While the other two core elements were not uniformly applied in the definitions, no core element was omitted by more than three (15%) of the examined citations, and no definition omitted more than one core element. Thus, while the definitions varied in the degree of specificity provided, there was generally agreement across all citations regarding the core elements proposed in this study. The proposed definition of stimulability testing in the introduction (“the assessment of an individual’s ability to change or modify a behavior, typically towards ‘normal’, utilizing therapeutic techniques or facilitators”), with the accompanying three core elements, is therefore supported based on the current literature. The definitions of stimulability level compiled within this review, on the other hand, were extremely varied in their presentation. Only seven articles (7%) provided a definition of stimulability level. The behavioral targets within these definitions ranged from extremely broad (e.g., “change a behavior”; Schneider, 2019 ) to a list of extremely specific measurements (e.g., acoustic, perceptual, and videostroboscopic measures of change; Dejonckere & Lebacq, 2001 ), and the measurement scale type was extractable for only five of the seven definitions. Perhaps most importantly, several of the definitions of stimulability level were nearly identical to those of stimulability testing. For example, Schnieder (2019) stated “Stimulability is defined as a patient’s ability to change a behavior when provided modeling and/or cueing” (p. 475). This definition was classified as definition of stimulability level, rather than stimulability testing like the nearly word-for-word definition provided by Hartley et al., 2017 (“the patient’s ability to modify voice production in response to direction and/or modeling”, p. 297) because of the context of the definition in both articles. The definition provided by Schnieder (2019) appeared immediately under the heading “Stimulability for Change”, implying that, in this context, the definition provided was for the level of change, rather than the assessment procedure. In contrast, the definition provided by Hartley et al. (2017) is within the context of a survey of assessment procedures utilized by SLPs, solidly implying that the definition is for stimulability testing rather than level. The use of nearly-identical definitions for separate concepts supports the need for standardization of definitions of both stimulability testing and stimulability level within the literature. The results of this literature review suggest a strong tendency to assume a shared understanding of the meaning of stimulability testing and stimulability level amongst readership, but a lack of actual consensus when providing definitions for these terms. While the results suggests moderate consensus on the definition of stimulability testing which generally aligns with the definition of stimulability testing proposed in this paper, definitions of stimulability level are currently extremely limited in both number and specificity. These discrepancies highlight a problematic disconnect that undermines the ability of both researchers and clinicians to communicate effectively regarding stimulability testing and stimulability level. Terminology Used to Refer to Stimulability Testing and Stimulability Level The second aim of this study was to evaluate terminology used to describe stimulability testing and stimulability level in the current literature. Stimulability testing was described used a wide range of terminology, as displayed in Table 4 . While 80% of the of the terms used did contain the expected root word “stimulate” in some way, nine different modifiers were used after the root word (“assessment”, “challenge”, “probe”, “protocol”, “session”, “task”, “testing”, “training”, “trial”). The remaining 20% of articles used terminology that described stimulability testing as a diagnostic procedure (“diagnostic probe”; e.g., Adessa, 2021 ; “diagnostic procedure”; Behrman, 2005 ) a therapeutic procedure (“trial therapy”; e.g., Shembel et al., 2021 ; “diagnostic therapy”; Andreassen et al., 2017 ), or used another term that suggested an evaluation of a patient’s ability to change (e.g., “dynamic testing”, Iwarsson, 2015 ; “evaluation of plasticity” Dejonckere & Lebacq, 2001 ; “ability to modify to model”; Hartley et al., 2017 ). Terminology used to refer to stimulability level was more consistent than stimulability testing; approximately 75% of articles utilized either the term “stimulability” or “stimulable” to refer to stimulability level. Of concern, however, the term “stimulability” alone was used by authors to describe both stimulability testing and stimulability level. “Stimulability” was most commonly used to refer to stimulability level, appearing in 51% of articles that discussed stimulability level; however, it was also the second-most frequently used term to use when referring to stimulability testing. This likely points to an underlying conflation between the concepts of stimulability testing and stimulability level, ultimately limiting the usefulness of the term “stimulability” for research and clinical practice purposes. There is therefore a need for clearer terminology usage when describing stimulability testing and stimulability level. Targets of Stimulability Testing and Stimulability Level An additional aim of this study was to examine the behavioral targets for stimulability testing across the literature. It is interesting to note the range of target behaviors specified in Tables 3 , 5 , and 7. The targets specified in definitions of stimulability testing and stimulability level were generally quite broad, frequently specifying targets such as “voice production” or “change a behavior”. In contrast, stimulability level targets extracted directly from article text ranged in their degree of specificity, sometimes remaining broad (“stimulable for a better voice”; Sund et al., 2021 , p. 2) and sometimes extremely specific (“stimulability to flow phonation and resonant voice in sustained phonemes as well as short phrases”; Gartner-Schmidt & Gillespie, 2021 ; p. 38). Additionally, many different categories of behavioral targets were represented in Table 7 , ranging from specific therapeutic facilitators such as those noted by Gartner-Schmidt & Gillespie (2021) , to categories of facilitators (“stimulability of voice therapy techniques”; Payten et al., 2022 ; p. 6), to more general behaviors (“stimulability for improved communication skills”; Behrman et al., 2020 , p. 1450), to assessments of candidacy (“stimulability for behavioral treatment”; Lewandowski et al., 2018 , p. 909). Therefore, there was a difference between the degree of specificity in behavioral targets specified in the definitions of stimulability testing and level compared to the degree of specificity extracted directly from the text. This suggests a disconnect between the conceptualization and actualization of stimulability testing and the subsequent measurement of stimulability level. A similar disconnect was seen in Young (2025) , where eight voice-specialized speech-language pathologists were interviewed regarding their methods of measuring stimulability level before and after performing mock stimulability testing trials on participants with healthy voices. In this study, all eight clinicians provided methods of measuring stimulability level after performing mock stimulability testing trials that they had not provided in their initial interviews, suggesting an unstable underlying conceptualization of what they were measuring when determining stimulability level. Together, the variety of behavioral targets seen for both stimulability testing and stimulability level in this review align with previous research suggesting a generally poor consensus and conceptualization of the underlying mechanisms being measured during stimulability testing for patients with voice disorders. Measurement Scale Classification for Stimulability Level Stimulability level has been described using several different measurement scales, ranging from a binary scale (i.e., “stimulable” vs “not stimulable”) to continuous scales. The results indicated that binary scales are the most used measurement scale type within the literature, occurring in 78% of articles, compared to 15% of articles using a categorical scale. Interestingly, this is the opposite trend compared to clinician reports; of the 88 practicing voice-specialized SLPs surveyed by Toles & Young (2023) , only 23% reported using a binary scale, compared to 67% who reported using categorical scales. This highlights a divergence between the usage of stimulability level in research and clinical practice. As seen in the current review, there are multiple potential behavioral targets for stimulability level; thus, for research purposes, it may simply be more straightforward to assign stimulability level to the binary “stimulable” vs “not stimulable” classification. In clinical practice, however, where more nuanced decision-making is required based on a patient’s response, a categorical scale of measurement may be required. Regardless of the cause, divergences between published literature and clinical practice serve to underline areas where further investigation is needed. Limitations The current review has several limitations. First, the author opted to use the key terms “stimulability” and “stimulable” when searching for articles regarding this topic in the formal literature search. It is possible that additional peer-reviewed literature exists examining practices essentially identical to stimulability testing described using different terminology that were not found using these methods. Additionally, the current review only included literature from peer-reviewed sources. This eliminated many potentially fruitful sources from consideration, including textbooks, theses, and dissertations. As noted in the introduction, many consider a textbook ( Boone, 1971 ) the basis of stimulability testing in voice disorders. Interestingly, however, Young (2025) found that descriptions of stimulability testing and stimulability level from an informal review of voice textbooks were generally quite poor. Young (2025) examined 17 textbooks and found that only 71% of them (12/17) described a procedure resembling stimulability testing, and only 12% (2/17) described stimulability level. Thus, a formal review of addition of sources of information outside of peer-reviewed journal articles could be an interesting avenue for future work. Future Directions The results of this literature review highlight many considerable gaps in the current literature regarding stimulability testing in voice disorders, suggesting the need for much future work. First, the term “stimulability”, when used in isolation, was used to describe an assessment procedure in 13% of examined articles but the results of the assessment in 51% of articles. The use of a single term to describe both stimulability testing and stimulability has led to confusion within the literature regarding these two constructs; there is a need for greater precision from authors so it is immediately clear to readers whether they are discussion stimulability testing vs stimulability level. Authors should additionally be aware that more than three quarters of the literature examined used terms such as “stimulability” or “stimulable” without providing a functional definition for either term. A standardized definition of stimulability testing was proposed in this manuscript which has sufficient evidence from the literature to be adopted going forward (“the assessment of an individual’s ability to change or modify a behavior, typically towards ‘normal’, utilizing therapeutic techniques or facilitators”). However, there is not currently sufficient consensus within the literature to support a standardized definition of stimulability level. Because of this, authors are called upon to ensure that their descriptions of stimulability testing, and particularly stimulability level, are sufficiently detailed so as to be replicable. Those that use stimulability testing regularly must also consider that stimulability level is theoretically what is used to make determinations regarding the various functions of stimulability testing. Unfortunately, many of the reported functions of stimulability testing currently have extremely limited literature supporting their validity in clinical practice ( Young, 2025 ). This may be in part to a failure to adequately and reliability describe stimulability level within the literature. The current review examined only the behavioral targets and measurement scales used when describing stimulability level, but other factors such as degree and type of cueing, length of practice, and practice context are all also considerations when determining stimulability level. Without adequate descriptions of stimulability level, a single term (“stimulable”) can describe anything from an individual who is makes change at the vowel level with extensive cueing to an individual who makes change in a conversational context with minimal cueing. Thus, the term itself loses much of its predictive value for aiding clinicians and researchers in establishing the relationship between stimulability level and the functions of stimulability testing. There is therefore a great need for clinicians and researchers to mindfully and transparently report what is being measuring when determining stimulability level in the literature. Conclusion The current review represents the first attempt to evaluate the current literature on stimulability testing in the context of voice disorders. Stimulability testing has a long history in speech-language pathology, particularly in clinical practice, but descriptions of this practice appears infrequently and under a myriad of different terms in the published literature. The results suggested conflation of stimulability testing (the assessment procedure) and stimulability level (the results of the procedure) by many authors, both of which appeared in this review under the term “stimulability”. Definitions of stimulability testing provided across the literature were relatively uniform, supporting the creation of a standardized definition of stimulability testing (“the assessment of an individual’s ability to change or modify a behavior, typically towards ‘normal’, utilizing therapeutic techniques or facilitators”). However, definitions of stimulability level were limited and varied, and many descriptions of stimulability level within the literature did not contain adequate detail to determine essential elements of stimulability level such as behavioral targets (e.g., forward resonance, increased loudness, etc.) or type of measurement scale (e.g., binary, categorical, etc.) Given the importance of adequately and validly quantifying stimulability level to use it determine causative relationships between stimulability testing and many of the functions of stimulability level, there is a great need for increased transparency in the literature when defining and describing stimulability testing and stimulability level. Data Availability All data produced in the present work are contained in the manuscript Acknowledgements This project was partially funded through the University of Utah CSD Department Seed Grant for Innovative Research. 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