Brendel & Zeigler (2008)


Group Analysis Form


SOURCE:  Brendel, B., & Ziegler, W. (2008).  Effectiveness of metrical pacing in treatment of apraxia.  Aphasiology, 22,  77-102.







•  Both techniques yielded similar gains in speech sound production

•  Metrical Pacing Technique:  expect improvement in duration and fluency\suprasegmental measures as well as in speech sounds

•  Conventional Therapy:  expect improvement in speech sounds only




1a.  What type of evidence was identified?  Prospective, Single Group, with Random Assignment to Alternating Treatments with a Cross-Over Design

1b.  What was the level of support associated with the type of evidence?  C+


2.  How was group membership determined?                 

2a.  Were participants randomly assigned to groups?           Yes

• each P received 2 sets of experimental/metrical  (metrical, M) treatment and  2 controls (C) treatments.  (Therefore, the groups were labeled as M1st and C1st.  See item #4 for explanation.)

•  Ps were assigned to subgroups  with randomized order

2b.  If participants were not randomly assigned to groups, were members of groups carefully matched?  N/A

3.  Was administration of intervention concealed?        

a.  from participants?  No  

b.  from clinicians?  No

c.  from analyzers?  No


4.  Were the groups adequately described? Yes

LIST NAMES OF GROUPS:   “M1st”  = M-C-M-C, N =  6; C1st = C-M-C-M, N + 4; (C= control treatment,  M= Metrical Pacing Therapy)


4a.      How many participants were involved in the study?

•  total # of participants: 10

•  # of groups: 2

•  # of participants in each group:  6, 4

•  Originally 18 volunteers but 8 volunteers excluded for various reasons


4b.  The following variables actively controlled described:       

•  age:  34-64 years; mean 54 years

•  gender:  5m, 5f

•  right handed:  all

•  left middle cerebral artery lesion:  all

•  basal ganglia lesion:  2

•  right hemiparesis:  all

•  language:  all German speaking

•  passed sentence repetition task:  all

•  mild dysarthria:  3

•  hearing WNL:  all

•  right hemiparesis: all (varying degrees of involvement and severity)

4c.  Were the groups similar before intervention began?  NA – only one group

4d.  Were the communication problems adequately described?  Yes       

•  disorder type:  Apraxia of Speech—used several  criteria to qualify

•  severity level:  varied

•  presence of dysarthria:  3

•  presence of aphasia:  9 had aphasia (different types/severity)


5.  Was membership in groups maintained throughout the study?


a.  Did each of the groups maintain at least 80% of their original members?  Yes and No

•  1 P was not post tested because he/she did only completed 3 sessions

•  2 Ps were missing at the follow up

•  all 8 remaining for the follow up  test had received therapy during that time

b.  Were data from outliers removed from the study?  No


6.  Was their acceptable control?  Only one group with controls

•  18 Ps originally; 8 excluded for various reasons not related to invention frustration

a.  Was there a no intervention phase?  No

b.  Was there a foil intervention phase? No

c.  Was there a comparison group?  Yes

d.  Was the time involved in the comparison phases constant?  Yes         


7.  Were the outcomes measure appropriate and meaningful?


7a.  List outcomes (dependent variables):

Derived from a sentence repetition task:

1.  duration of sentences

2.  proportion of dysfluencies

3.  segmental (phoneme and phonetic) errors per sentence

Derived from clinical tests:

4.  word/nonword repetition  (Hierarchical Word List)

5.  Token Test

6.  conversational score* improved segmental accuracy pre post

7.  rapid syllable repetition* increased syll per sec pre post


7b.  Are the outcome measures subjective?  Yes for 2, 3, 4, 5, 6, 7

7c.  Are the outcome measures objective?  Yes for #1          


8.  Were reliability measures provided?

a.  Interobserver for analyzers?  Yes:  .79 – .99

b.  Intraobserver for analyzers?  No

c.  Treatment fidelity for clinician?  No but the same clinician administered all sessions.


9.  What were the results of the statistical (inferential) testing?

9a.  List the order of improvement on the outcome measures

•  The  2 groups (MPT and traditional interventions) were not compared.

Pre and Post Intervention:

•  overall outcome following both MPT + traditional interventions (although administered in different orders):  overall pre and post test scores were significantly different for

–  rapid syllable repetition (faster),

–  conversational score (articulation accuracy increased).

–  segmental accuracy of word and nonword repetition (increased).

–  segmental accuracy in sentence repetition task (increased).

–  duration of sentences  in sentence repetition task (decreased),

–  proportion of dysfluencies in sentence repetition task (decreased) .

•  Results were corrected for spontaneous recovery in DUR measures.

•  sentence duration shorter for MPT

•  dysfluencies significantly less in MPT

•  both control and MPT had significant differences (pre-post) but not between groups in scores for segmental errors


Follow Up (at least 8 weeks after intervention)

•  Authors claimed 8 Ps participated in this phase, I count 7 patients, unless the P removed from post test was included in this analysis.

•  Outcomes #1-3 (only measures reported) continued to be significantly better than pretest.

•  However, 5/8 Ps had remained in outpatient treatment.

MPT vs Conventional

•  Authors collapsed data, MPT showed significantly (p < .001) more improvement than Conventional therapy for duration and  dysfluencies (Outcomes #1 & 2).


9b.  Was there a significant difference in outcome measures following treatment?


•  for  pre vs post test with combined treatments 1, 2, 3, 4, 6, 7

9c.  What was the p value? .05-.001

9d.  Was confidence interval (CI) provided? No


10.  What is the clinical effect?  (i.e., EBP measures; check measure reporting

Not provided




PURPOSE:  To compare outcomes of intervention when P synchronizes production of syllables in target utterances with a rhythmic tone.

POPULATION:  Apraxia of speech (Ps were German speakers)


MODALITY:  Production


ELEMENTS OF PROSODY TARGETED (Dependent variable):  fluency (tempo-  rate-duration; tempo–rate-phrasing)


OTHER ASPECTS OF LANGUAGE TARGETED (Dependent variable):  articulation (segmental) accuracy—phonetic and phonemic errors were scored separately but were collapsed for analysis

DOSAGE:  10 weeks with a 10-14 day baseline.  Each treatment phase consisted of eight 50 minute session over 2 weeks.  There was a total of 4 phases:  2 control and 2 experimental (MPT) for the participant




For MPT (Metrical Pacing Therapy): 


1.  For each session:  15 sentences were designed to match articulatory and language skills of the specific P.

2.  C recorded each sentence using natural prosody and normal rate of speech.

3.  The sentences were entered into a computer program designed to present appropriate pacing for each sentence.  The syllable onsets were identified.

4.  The onsets formed the metrical template.  The speech was removed and tones signifying what had been syllable onsets (tone sequences) were inserted.

5.  Tone sequences were repeated 6-12 times with pauses between sentences.


For the most part, MPT and control interventions used the same hierarchy:

•  utterance length:  words = 1-6 syllables; phrases  = 2-10 syllables

•  syllable complexity:  1-3 syllables words were ranked for complexity relative to speech-motor complexity which was defined as

1.  # of primary articulators involved in the syllable

2.  oral/nasal patterns

•   MPT also modified rate:  faster as P progressed; slower if needed to be insure a high rate of  success. (See Fig 2, p. 83.)






•  included rhythm/rate control that is computer mediated.

•  P’s task:  to match production of the targeted utterance to prescribed rhythm

•  Steps in acoustic stimulation cueing natural rhythm:

1.  P and C are seated in front of a computer.

2.  Clinician familiarizes P with the target sentences:

a.  C reads the target sentence aloud several times.

b.  P listens to the acoustic pacing signals several times.

c.  C directs P to

•  use acoustic signals as a guide and not to attempt exact synchrony

•  avoid focusing on articulation

•  attempt to be fluent

3.  P hears prerecorded acoustic signals representing the natural rhythm of a specific sentence.

4.  P produces the target sentence using the pacing rhythm.  C records P’s attempt.

5.  P and C review the production.  C provides feedback about fluency and rate derived from visual representation of acoustic properties.  Although C provides feedback about fluency and rate; C does not provide feedback about articulatory accuracy.

6.  If necessary. C provides additional feedback and scaffolding such as verbal description, modeling, rhythmic tapping, visual cues, joint P and C production (chorus speaking), and reducing task complexity.  C gradually fades support.

Conventional Intervention

•  C did not provide exercises targeting rate or rhythm.

•  C used traditional therapy techniques such as

–  phonetic placement

–  gestural facilitation

–  integral stimulation

–  minimal pairs

–  word derivation exercises

•  C’s use of therapy techniques and type of stimuli (visual, verbal, tactile)  was individualized for the Ps.

•  Cs administered techniques that were most facilitative for the individual P.




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