Hartelius et al. (1997)

EBP THERAPY ANALYSIS for

Single Subject Designs

 

SOURCE:  Hartelius, L., Wising, C., & Nord, L.  (1997). Speech modification in dysarthria associated with Multiple Sclerosis: An intervention based on vocal efficiency, contrastive stress, and verbal repair strategies. Journal of Medical Speech-Language Pathology, 5, 113-140.

 

REVIEWER(S):  pmh

 

DATE:   2.13.13

ASSIGNED OVERALL GRADE: D+

 

TAKE AWAY:  This article provides variable support that the program improved contrastive stress, voice quality (pitch and loudness), articulatory precision, and naturalness but not verbal repairing in speakers with MS.  The overall quality rating is influenced by the design and the variable responses of the Ps.

                                                                                                                       

1.  What was the focus of the research?  Clinical Research

                                                                                                           

2.  What type of evidence was identified?                              

a.  What  type of single subject design was used?  Case Studies: Case Series  (Although these were categorized as single subjects, in some cases the investigators combined data for  inferential statistical analyses.  These will be noted below.)

b.  What was the level of support associated with the type of evidence?  Level = _C+_  

                                                                                                           

3.  Was phase of treatment concealed?

a.  from participants?  No

b.  from clinicians?  No

c.  from data analyzers?  Yes

 

4.  Were the participants adequately described?  Yes

a.  How many participants were involved in the study?  7

b.  The following characteristics were described:

•  age:  28-49 years

•  gender:  6f, 1m

•  cognitive skills:  not tested but all appeared WNL

•  expressive language:  not tested but all appeared WNL; Swedish speakers 

•  time since diagnosis:  4-18 years

•  diagnosis:  Multiple Sclerosis (MS)

•  Progressive stage of MS:  relapsing-remitting (2), secondary progression (4),  primary progression (1)

•  vision:   2 Ps WNL, 5 Ps reduced acuity but could read standard reading materials

•  EDSS (disability status):  3.5-8.5 (0= no symptoms; 10 = death due to MS)

•  Other (list):

c.  Were the communication problems adequately described? Yes

•  The disorder type(s) were  all Ps cerebellar dysarthria, 4Ps also spastic dysarthria   

•  Other aspects of communication that were described:

–  hearing:  all Ps claimed no problems

–  speech and respiratory characteristics:

•  upper thoracic and uncoordinated respiratory movements

   •  high pitched voice

   •  harsh/strained voice quality

   •  imprecise articulation due to slow and weak oral musculature

   •  slow speech

   •  monotony

   •  equal and excessive stress

–  5 Ps subjected to laryngostroboscopic; concerns varied including

•  slow movement of the left vocal fold during ab- and adduction

   •  asymmetry

   •  hyperadduction

   •  incoordination

   •  intent tremor

                                                                                                                       

5.  Was membership in treatment maintained throughout the study?  Yes

a.  If there was more than one participant, did at least 80% of the participants remain in the study?  Yes

b.  Were any data removed from the study?  No

 

6.  Did the design include appropriate controls?  No, these were case studies.

a.  Were baseline/preintervention data collected on all behaviors?  Yes

b.  Did probes include untrained data?  Yes

c.  Did probes include trained data?  No

d.  Was the data collection continuous?  No

e.  Were different treatment counterbalanced or randomized?  No

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes (dependent variables) were

  OUTCOME #1:  Improved articulatory precision rating of one sentence from a read paragraph 

  OUTCOME #2:  Improved voice rating (i.e., levels and variability of pitch and loudness) of one sentence from a read paragraph 

  OUTCOME #3:  Improved naturalness rating (i.e., closer to normal speech) of one sentence from a read paragraph 

  OUTCOME #4:   Increased percentage of correctly identified stressed words from one read sentence

  OUTCOME #5:   Improved perceived stress patterns (i.e., judges designated the most stressed word and degree of stress of other targeted words) in a single read sentence

  OUTCOME #6:  Improved acoustic measures of contrastive stress

  OUTCOME #7:  Improved perception verbal repairing (i.e., response to clarification request of a sentence from a read paragraph)

  OUTCOME #8:  Improved acoustic measures of verbal repairing (i.e., response to clarification request of a sentence from a read paragraph)

 

b.  The outcomes that are subjective: Outcomes #1-5, &        7       

c.  The outcomes that are objective:  Outcomes #6, 8                       

d.  The outcome measures that are supported with reliability data: Outcomes #1-5, & 7                                  

e.  Supporting reliability data for each outcome measure:

  OUTCOMES #1, 2, 3 (Improved articulatory precision, voice rating, naturalness rating)  Intrajudge = 89%; Interjudge =  in 48% of judgments all 3 judges agreed; in 52% of judgments, 2 of 3 judges agreed)

OUTCOME #4: Increased percentage of correctly identified stressed words from one read sentence  Intrajudge = 100%; Interjudge = range 42%-100%, mean 82%

OUTCOME #5:  Improved perceived stress patterns (i.e., judges designated the most stressed word and degree of stress of other targeted words) in a single read sentence   Intrajudge reliability, Spearman rho range = 0.78-0.99; Interjudge reliability, Spearman rho = 0.6

OUTCOME #6:  Improved acoustic measures of contrastive stress

OUTCOME #7:  Improved perception verbal repairing (i.e., response to clarification request of a sentence from a read paragraph)   Intrajudge reliability was 69%; Spearman rho range – 0.79 = 1.00

OUTCOME #8:  Improved acoustic measures of verbal repairing (i.e., response to clarification request of a sentence from a read paragraph)

 

8.  Results:

a.  Did the target behavior improve when it was treated?  Inconsistent results

b. The overall quality of improvement of the outcomes

  OUTCOME #1:  Improved articulatory precision rating of one sentence from a read paragraph—2Ps strong; 2 Ps moderate;  Ps ineffective; 1P contraindicated

OUTCOME #2:  Improved voice rating (i.e., levels and variability of pitch and loudness) of one sentence from a read paragraph—4Ps strong; 1P ineffective; 2Ps contraindicated

OUTCOME #3:  Improved naturalness rating (i.e., closer to normal speech) of one sentence from a read paragraph—3 Ps strong; 1 P moderate; 1P ineffective; 2Ps contraindicated

OUTCOME #4:   Increased percentage of correctly identified stressed words from one read sentence—4Ps were able to perform this task before and after intervention and are not discussed here; 2Ps strong; 1P ineffective

OUTCOME #5:   Improved perceived stress patterns (i.e., judges designated the most stressed word and degree of stress of other targeted words) in a single read sentence – See Outcome #6 which acoustically measured selected stressed and unstressed words.

OUTCOME #6:  Improved acoustic measures of contrastive stress— overall total durations and durations of stressed words did not increase significantly–ineffective; increased maximum fo and fo variability  for stressed word — limited; intensity results—not clear

OUTCOME #7:  Improved perception verbal repairing (i.e., response to clarification request of a sentence from a read paragraph) – Ineffective for for 5Ps; 2 Ps moderate support

OUTCOME #8:  Improved acoustic measures of verbal repairing (i.e., response to clarification request of a sentence from a read paragraph)   See Outcome #7

9.  Description of baseline:

a.  Were baseline data provided?  Yes. Actually, they were just preintervention data.

•  Outcomes #1-8:  one preintervention data point each.

b.  Was baseline low and stable? NA

c.  The percentage of nonoverlapping data (PND)–  was not provided and thee were insufficient data for reviewers to calculate PND.

d.  Does inspection of data suggest that the treatment was effective?  NA

 

10.  What was the magnitude of the treatment effect?  NA

 

11.  Was information about treatment fidelity adequate?  Not Provided

 

12.  Were maintenance data reported?  No  __x__

 

13.  Were generalization data reported? Yes

•  Pre and Post testing involved untrained read sentences and paragraphs.

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION:  D

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate the effectiveness of an intervention program for improving communication of speakers with MS by focusing on maximizing vocal efficiency, contrastive stress, and verbal repairs.

POPULATION:  MS

 

MODALITY TARGETED:  expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED:  loudness (level, variability); pitch (level, variability); contrastive stress; duration

 

ELEMENTS OF PROSODY USED AS INTERVENTION (part of independent variable):  stress, pitch, loudness, duration.

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED (Dependent variable):  naturalness, articulatory precision, verbal repairing

DOSAGE:  varied—individual (from 4-9 sessions, all Ps) and group (7-11 sessions, 5 Ps); 45 minutes- 1 hour, 3 weeks – up to 4 months

 

ADMINISTRATOR:  SLP

 

STIMULI:  auditory, visual (sentences and paragraphs to read), audiorecorder, conversation

GOAL ATTACK STRATEGY:   vertical and horizontal

 

MAJOR COMPONENTS:

 

Three major components:

1.  Basic vocal exercises

2.  Contrastive stress exercises

3.  Verb repair exercises

1. Basic vocal exercises

1a.  initial exercises for postures, overall relaxation, abdominal (relaxed) breathing.

1b.  then, exercises for respiratory support and effort. Targets included

•  initiation of speaking with high lung volume to decrease spacitity

•  increased stability of phonation

•  use of abdominal muscles to control loudness

Exercises included

•  easy onsets for vowels, syllables, words

1c.  exercises for varying

•  loudness

•  pitch

Contexts included

•  short phrases

•  sentences

2. Contrastive stress exercises (based, in part, on the work of Rosenbek & LaPointe, 1985)

Step 1:

•  C provides the same written sentences for C and P.

•  C models the sentence with the targeted stressed word.

•  P identifies the targeted word on the written sentence

Step 2:

•  C and P discuss the different meanings associated with the different stress patterns.

•  P reads the sentences with varying placements of the stress.  (This is audiorecorded.)

•  C identifies the perceived stress placement of the sentence produced by P.

•  C and P discuss the P’s performance including the following topics:

–  P’s strategy for producing stress

–  Reason’s why C misperceived P’s intent

–  Reviews of recording P’s attempt

–  Identification of challenges (i.e., is one location in the sentence more difficult to stress than others?)

–  Identification of alternate strategies for producing stress (e.g., loudness, duration, pitch change, pause)

Step 3

•  C prepares a written passage with targeted stressed words.  C insures that there is variation within paragraph.

•  C reads aloud the paragraph with P identifying perceived stresses on a written copy of the paragraph.

•  P reads aloud the paragraph with C identifying perceived stresses on a written copy of the paragraph.

•  P prepares (by marking targeted stressed words)  a new paragraph with sharing targets beforehand with C.

•  C identifies the perceived stresses on a written copy of the paragraph.

•  C trains P to self-monitor his/her stressing and to generalize stressing in conversation

3. Verb repair exercises

•  These exercises occurred during reading or conversation activities.

•  Although the Ps all had imprecise articulation, this was not directly targeted in these or any of the other exercises

•  C or, if during a group session, other Ps request clarifications.  (The clarification request could be issued when part of all of an utterance was unintelligible or when the listener believe the P could have produced a clearer utterance.)

•  Ps are encouraged to consider the following when asked to clarify:

–  parts of the utterance that should be repeated

–  strategies for repeating the utterance

–  strategies for stressing words (e.g., duration, pitch, loudness, pause)

•  Ps are encouraged to self-monitor and clarify when they thought they cold be clearer.

Procedural Schedule

•  Sessions #1-3 or 4:  Basic Vocal exercises

•  Sessions after #3 or 4:  Introduced Contrastive Stress exercises and Verb Repair exercises.  Some Basic Vocal exercises were included in each of the sessions.

DEPENDENT VARIABLE(S)/OUTCOME(S):  (List prosodic outcomes only)

  OUTCOME #1:  Improved articulatory precision rating of one sentence from a read paragraph 

  OUTCOME #2:  Improved voice rating (i.e., levels and variability of pitch and loudness) of one sentence from a read paragraph 

  OUTCOME #3:  Improved naturalness rating (i.e., closer to normal speech) of one sentence from a read paragraph 

  OUTCOME #4:  Increased percentage of correctly identified stressed words from one read sentence

  OUTCOME #5:  Improved perceived stress patterns (i.e., judges designated the most stressed word and degree of stress of other targeted words) in a single read sentence

  OUTCOME #6:  Improved acoustic measures of contrastive stress

  OUTCOME #7:  Improved perception verbal repairing (i.e., response to clarification request of a sentence from a read paragraph)

  OUTCOME #8:  Improved acoustic measures of verbal repairing (i.e., response to clarification request of a sentence from a read paragraph)

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