Blanchet & Snyder (2010)



Source: Blanchet, P. G., & Snyder, G. J.  (2010).  Speech rate treatments for individuals with dysarthria:  A tutorial.  Perceptual and Motor Skills, 110, 965-982.


Reviewer(s): pmh


Date:  12.28.12                                            Level of Evidence:  D


Overall Assigned Grade:  D+


Take Away:  Moderate support for using rigid rate control approaches for clients with severe dysarthria and more naturalistic approaches for clients with less severe dysarthria.


What type of secondary review?  Narrative Review


1.  Were the results valid? Yes

a.  Was the review based on a clinically sound clinical question?  No

b.  Did the reviewers clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)?  No

c.  Authors noted that they reviewed the following resources: (place X next to the appropriate resources)—did not report x

 d.  Did the sources involve only English language publications?  Yes

e.  Did the sources include unpublished studies?  No ___

f.  Was the time frame for the publication of the sources sufficient?  Yes

g.  Did the reviewers identify the level of evidence of the sources? No

h.  Did the reviewers describe procedures used to evaluate the validity of each of the sources?  Yes

i.  Was there evidence that a specific, predetermined strategy was used to evaluate the sources?  No

j.  Did the reviewers or review teams rate the sources independently? No

k.  Were interrater reliability data provided?  No

l.  If the reviewers provided interrater reliability data, list them:  NA

m.  If there were no interrater reliability data, was an alternate means to insure reliability described?No

n.  Were assessments of sources sufficiently reliable?  No

o.  Was the information provided sufficient for the reader to undertake a replication?  No  

p.  Did the sources that were evaluated involve a sufficient number of participants?  No

q.  Were there a sufficient number of sources? Yes


2.  Description of outcome measures:

The outcome measures were

•  Outcome #1:  changes in speaking rate (articulation time, pause time)

•  Outcome #2:  changes in intelligibility

•  Outcome #3:  changes in prosody


3.  Description of results:


a.  What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? none provided

b.  Summary of the overall findings of the secondary review:


The literature concerned with rate modification of speakers with dysarthria can be organized using a hierarchical strategy from rigid control to more naturalistic approaches.  The most rigid approaches can modify rate but have negative effects on other aspects of prosody; they are recommended for individuals with severe dysarthria to allow for oral communication.  The more naturalistic approaches generally require more training for the C and P but results are more socially acceptable.


c.  Were the results precise?  No 

d.  If confidence intervals were provided in the sources, did the reviewers consider whether evaluations would have varied if the “true” value of metrics were at the upper or lower boundary of the confidence interval? Not Applicable 

e.  Were the results of individual studies clearly presented?  Yes

f.  For the most part, were the results similar from source to source? Unclear/ Variable

g.  Were the results in the same direction?  Yes

h.  Did a forest plot indicate homogeneity?  Not Applicable

i.  Was heterogeneity of results explored?  Yes

j.  Were the findings reasonable in view of the current literature? Yes

k.  Were negative outcomes noted? Unclear/VariableSome of the reviewed articles presented data indicating that a program was not totally successful.


NOTE:  for a narrative review, the authors provided quite a bit of information.





For each procedure detailed in the review, provide the following information:


NOTE:  Procedures are organized from most intrusive (rigid) to least intrusive (naturalistic)


Description of Procedure #1(Pacing Boards)

•  The P tapped blocks representing each syllable as he spoke.

•  The words were spoken syllable-by-syllable with equal duration for each syllable.


Evidence Supporting Procedure #1(Pacing Boards; 2 studies with a total of 2 Ps)

•  Ps showed improvement as measures by the lack of palilalia, increased intelligibility, and decreased disfluencies.

•  Other positives include low cost, ease of instruction and use.


Evidence Contraindicating Procedure #1(Pacing Boards; 2 studies with a total of 2 Ps)

•  Requires a level of visual and manual skills.

•  One word or syllable at a time disrupts prosody.



Description of Procedure #2—(Alphabet Board Supplementation)

•  This approach involved a modification of a traditional Alphabet Board.

•  Ps paired oral speech with the use of an Alphabet Board.

•  The modifications included

1.  P indicating the initial letter of each word as he/she spoke it.

2.  C repeating the word after the P to verify he/she understood the P.

3.  If the C was wrong, the P shook his/her head and repeated #1.

4.  If C continued to experience problems, P spelled the entire word.

5.  P also had word/phrases available to point to as communication needs dictated:  “End of sentence, ” “End of word,” “Repeat,” and “Start Again.”

6.  Instructions regarding how to communicate with the P were mounted on the board.


Evidence Supporting Procedure #2—(Alphabet Board Supplementation; 2 studies with a total of 8 Ps)

•  Data on words per minute and intelligibility of words and sentences revealed that 2 Ps intelligibility improved using Alphabet Board Supplementation.

•  Another study indicated that rate of appropriated targeted consonants improved with the use of Alphabet Board Supplementation.  It is not clear why this is happening—could be pauses give Ps more time to focus on consonant targets.


Evidence Contraindicating Procedure #2—(Alphabet Board Supplementation; 2 studies with a total of 8s)

•  Requires a level of visual, manual, and spelling skills.

•  One word at a time with spelling task disrupts prosody.


Description of Procedure #3—(Visual and Auditory Feedback)

•  C generally uses technology to provide feedback to the P regarding the quality of his/her productions.

•  C pre-records a model using an oscilloscope or a visipitch or Praat.

•  P listens to the model that is accompanied by a visual representation of pitch, loudness, and/or duration.

•  C then directs P to reproduce what had been modeled.

•  C records the P’s attempt on the technology.

•  P analyzes his/her attempts by comparing them to the model.


Evidence Supporting Procedure #3—(Visual and Auditory Feedback; 2 studies with a total of 2 Ps)

•  Results indicate changes in rate and intelligibility.

•  One study reported evidence of partial maintenanceof improvement 10 weeks after the termination of therapy.

•  This approach to rate reduction tends to preserve prosody.


Evidence Contraindicating Procedure #3—(Visual and Auditory Feedback; 2 studies with a total of 2 Ps)

•  Requires training on the part of C and P.

•  Improvement is not immediate, may take a 9-10 weeks.

•  P needs to be cognitively and visually intact.

•  Fading tends not to be included in programming which may limit generalization to natural contexts.


Description of Procedure #4—(Cueing and Pacing Strategies)

•  A number of procedures are included in this set of strategies:

1.  Rhythmic cueing—C slows P’s rate by pointing to words read by P using a natural rhythm.  For example, stressed words may be of longer duration than unstressed words.  Ps are permitted to lag behind the C’s points but not precede them.  C gradually fades pointing cues.

   2.  Computerized rhythmic cueing—C reads the passage into a computer and selects target rates.  Using the computer, the C manipulates presentation style and timing:

a.  additive metered condition—one word at a time appears on the computer screen with equal duration for each word

b.  additive rhythmic condition– one word at a time appears on the computer screen with a more natural timing pattern related to the number of syllables in a word.

c.  cued-metered—a whole passage appears on the screen at a rate selected by C but  with a cursor cueing words of equal duration.

d.  cued-rhythmic- – a whole passage appears on the computed screen with a more natural timing pattern related to the number of syllables in a word.


Evidence Supporting Procedure #4—(Cueing and Pacing Strategies—2 studies with a total of 12 participants, only 8 were clinically impaired)

•  Rate decreases and intelligibility increases with limited negative impact on prosody.

•  The greatest improvement in intelligibility occurred with the cued-metered procedure.

•  Computerized programs may reduce the amount of time needed for positive change.


Evidence Contraindicating Procedure #4—(Cueing and Pacing Strategies—2 studies with a total of 12 participants, only 8 were clinically impaired)

•  Some of these approaches take a long time to result in positive change.

•  Requires training on the part of C and P.

•  P should be cognitively and visually intact


Description of Procedure #5—(Delayed Auditory Feedback, DAF)

•  Using earphones, C manipulates auditory feedback to the P of his/her speech so that the signal is slightly delayed.

•  It is believed that this delay causes the P to speak more slowly by prolonging vowels, stabilizing syllable duration, and smoothing syllable transitions.


Evidence Supporting Procedure #5—(Delayed Auditory Feedback, DAF; 6 studies, 7 participants reported, reviewers did not note number for one study)

•  The delay can be minimize and faded.

•  For those who cannot generalize to natural contexts, portable technology is available which allows DAF to serve a prosthetic function.

•  Improvements have been noted in speaking rate, intelligibility, intensity, acoustic/phonetic aspects of speech production,


Evidence Contraindicating Procedure #5—( Delayed Auditory Feedback, DAF; 6 studies, 7 participants reported, reviewers did not note number for one study)

•  For many Ps, DAF may work while it is being worn but does not have an effect in contexts in which the DAF in not engaged.  One set of authors (Downie et al., 1981) likened this to the effect of glasses—they improve vision when they are being worn but have no effect when they are not worn.

•  C’s need to be trained to administer DAF in the most effective manner including, perhaps, identifying the best relationship between delay of the signal and rate adjustments.

•  Some Ps may need direct, explicit instruction regarding how to use DAF.

•  DAF may work in some contexts (e.g., reading) but not in others (e.g., conversation).



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