Countyman et al. (1994)

EBP THERAPY ANALYSIS for

Single Subject Designs

 

SOURCE:  Countryman, S., Ramig, L. O., & Pawlas, A. A. (1994). Speech and voice deficits in Parkinsonian plus syndromes:  Can they be treated? Journal of Medical Speech-Language Pathology, 2, 211-225.     

 

REVIEWER(S):  pmh  

 

DATE:  1.07.13                                 ASSIGNED OVERALL GRADE: C

 

TAKE AWAY:  Adds to the strong body of research supporting the effectiveness of Lee Silverman Voice Treatment.  The participants in this research were diagnosed with Parkinsonian plus syndromes.    

           

 

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 Study- Description with Pre and Post Test Results       

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

Level =  D+                                                      

                                                                                                           

3.  Was phase of treatment concealed?                                             

a.  from participants? No                              

b.  from clinicians? No                                  

c.  from data analyzers? Not clear             

 

4.  Were the participants adequately described?     Yes

a.  How many participants were involved in the study?  List here:  3           

b.  Were the following characteristics/variables actively controlled or described?

•  List  of described characteristics:

   •  age:  59-73

   •  gender:  1m, 2f                         

   •  cognitive skills: overall mild impairment for 2 Ps.  1 P could not be tested due to visual and motor limitations        

   •  medications:  all Ps took medications which varied

   •  years post diagnosis:  3-4 years

   •  mobility:  all Ps were wheelchair users

   •  psychosocial issues:  all Ps reported depression (varying degrees of severity); each of the Ps admitted to one or more of the following:  fatigue, emotional lability, nervousness, tension, anxiety, stress

                                                                                                             

c.  Were the communication problems adequately described? Yes

•  List the disorder type(s):  Parkinsonsian plus syndrome (PPS); 1P =  multiple system atrophy (MSA); 1P =  Shy-Drager syndrome; 1P = progressive neurological disease (PSP)

•  List other aspects of communication that were described: 

     –  severity of speech disability:  severe (1P); moderate to severe (2Ps)

     –  stage of Parkinson disease:  III (for 1 P); IV (for 2 Ps)

     –  speech mechanism:  variety of limitations; all Ps had some problems

     –  swallowing: varied from no problem (2Ps) to problems with liquids and solids (1P)

     –  speech and voice:  all Ps had problems; they varied for the Ps but problems included reduced loudness, limited loudness variation, breathiness, aphonia, vocal flutter (rapid vocal tremor), low pitch, monotonicity, rough voice, wet/gurgle quality, reduced stress, reduced articulatory precision (slurring), rate, vocal fry, weak voice, reduced respiratory support,

     –  overall communication ratings by Ps and families:  variety of problems including reduced to limited functional communication,  limited initiation and maintenance of conversation

                                                                                                                       

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, but some data were not collected due to P limitations.

 

6.  Did the design include appropriate controls? No, this is a case study. 

a.  Were baseline/preintervention data collected on all behaviors?  Yes; there were 2 preintervention data collection points (baseline) for each P

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.  List the outcome(s) of interest (dependent variable) next to a number; add numbers as appropriate:  

  OUTCOME #1:  Intensity of sustained vowels

  OUTCOME #2:  Maximum duration of sustained vowels

  OUTCOME #3Mean fo of sustained vowels

  OUTCOME #4:  Intensity during reading and speaking (conversation)

  OUTCOME #5:  Mean fo during reading and speaking (conversation)

  OUTCOME #6fo  variability during reading and speaking (conversation)

  OUTCOME #7:  Single word intelligibility

  OUTCOME #8:  Overall intelligibility

  OUTCOME #9Loudness

  OUTCOME #10: Monotonicity

  OUTCOME #11:  Imprecise articulation (slurring)

  OUTCOME #12:  Forced vital capacity

  OUTCOME #13:  Videostroboscopic evaluation

 

b.  List numbers of the outcomes that are subjective:  #7-#11, #13

c.  List numbers of the outcomes that are objective:  #1-#6, #12

d.  List the number of the outcome measures that are reliable:   #1-#11

e.  List the data supporting reliability of each outcome measure; the numbers should match item 7a.

  OUTCOMES #1-#6:  0.96-0.99  (intraobserver)

  OUTCOME #7:  1.00 (interobserver)

  OUTCOMES #8-#11: 0.95-0.99 (intraobserver)

  OUTCOMES #12, #13:  Not reported

 

 

8.  Results:

a.  Did the target behavior improve when it was treated?  Yes, on many of the variables but not all the change was maintained over

b.   For each of the outcomes, list the overall quality of improvement as strong, moderate, limited, ineffective, contraindicated(The numbers should match the numbers in item 7a.)

  OUTCOME #1:  Intensity of sustained vowels –P1–moderate; P2–moderate; P3–strong

  OUTCOME #2:  Maximum duration of sustained vowels–P1–moderate; P2–limited;  

  OUTCOME #3:  Mean fo of sustained vowels—ineffective all Ps

  OUTCOME #4:  Intensity during reading and speaking (conversation–)

 P1–moderate; P2–moderate; P3–strong

  OUTCOME #5:  Mean fo during reading and speaking (conversation)

  OUTCOME #6fo  variability during reading and speaking (conversation)– P1–strong; P2–strong;  P3–strong

  OUTCOME #7:  Single word intelligibility—P2–moderate

  OUTCOME #8: Overall intelligibility– P1 moderate-strong; P2 moderate; P3 strong

  OUTCOME #9:  Loudness— P1 moderate-strong; P2 strong-limited;  P3 moderate-strong

  OUTCOME #10:  Monotonicity –P1 moderate-strong; P2 moderate-limited; P3 strong

  OUTCOME #11:  Imprecise articulation (slurring)— P1 strong; P2 strong-moderate; P3 strong

  OUTCOME #12:  Forced vital capacity—ineffective all Ps

  OUTCOME #13: Videostroboscopic evaluation – P1 (obtained 10 months post intervention); P2;  P3 (obtained 6 months post intervention) limited

 

 

9.  Description of baseline:

 

a.  Were baseline data provided? 

  OUTCOME #1:  Intensity of sustained vowels  Yes

  OUTCOME #2:  Maximum duration of sustained vowels  Yes

  OUTCOME #3Mean fo of sustained vowels  Yes

  OUTCOME #4:  Intensity during reading and speaking (conversation)  Yes

  OUTCOME #5:  Mean fo during reading and speaking (conversation)  Yes

  OUTCOME #6fo  variability during reading and speaking (conversation)  Yes

  OUTCOME #7:  Single word intelligibility   No

  OUTCOME #8:  Overall intelligibility  No

  OUTCOME #9Loudness  No

  OUTCOME #10: Monotonicity  No

  OUTCOME #11:  Imprecise articulation (slurring)  No

  OUTCOME #12:  Forced vital capacity  Yes

  OUTCOME #13: Videostroboscopic evaluation  No

 

b.  Was baseline low (or high, as appropriate) and stable? (The numbers should match the numbers in item 7a.)

  OUTCOME #1:  Intensity of sustained vowels—all Ps, yes

  OUTCOME #2:  Maximum duration of sustained vowels  –P1 short and sable; P2 longer and stable; P3 unstable

  OUTCOME #3Mean fo of sustained vowels –P1 unstable; P2 & 3 moderate and stable

  OUTCOME #4:  Intensity during reading and speaking (conversation)—yes all Ps

  OUTCOME #5:  Mean fo during reading and speaking (conversation)—P1 low and stable; P2 moderate and stable; P3 unstable

  OUTCOME #6fo  variability during reading and speaking (conversation) –P1 & P2 low and stable; P3 some instability

  OUTCOME #12:  Forced vital capacity—all low and stable

 

c.  What was the percentage of nonoverlapping data (PND)?  Not provided; PND could not be calculated from the results.

 

d.  Does inspection of data suggest that the treatment was effective? )?  Not provided; PND could not be calculated from the results.

           

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

 

11.  Was information about treatment fidelity adequate?   Not Provided

 

12.  Were maintenance data reported?  Yes

 

  OUTCOME #1:  Intensity of sustained vowels—P1 deteriorated; P2 deteriorated; P3 deteriorated

  OUTCOME #2:  Maximum duration of sustained vowels—P1 deteriorated; P2 deteriorated;

  OUTCOME #3Mean fo of sustained vowels

  OUTCOME #4:  Intensity during reading and speaking (conversation) —P1 deteriorated; P2 deteriorated for reading but not conversation; P3 deteriorated

  OUTCOME #5:  Mean fo during reading and speaking (conversation) —P1 deteriorated

  OUTCOME #6fo  variability during reading and speaking (conversation) — P2 deteriorated;

  OUTCOME #7:  Single word intelligibility—only 1 P showed progress in the original post intervention assessment

  OUTCOME #8:  Overall intelligibility—P1 deteriorated; P2 deteriorated;

  OUTCOME #9Loudness –—P1 deteriorated; P2 deteriorated; P3 deteriorated (only family member rated as deteriorated; P did not)

  OUTCOME #10: Monotonicity—P1 deteriorated; P2 deteriorated P3 deteriorated; P3 deteriorated (only P rated as deteriorated, family member did not)

  OUTCOME #11:  Imprecise articulation (slurring) —P1 deteriorated; P2 deteriorated; P3 deteriorated

  OUTCOME #12:  Forced vital capacity—this did not change but none of the Ps had shown improvement at first post intervention assessment

  OUTCOME #13:  Videostroboscopic evaluation; —not applicable

 

 

Many of the measures deteriorated to pre intervention or lower; in other cases the measures while deteriorated were still better than pre intervention.

 

 

NOTE:  Very thorough description of Ps.

 

 

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

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate the effectiveness of the Lee Silverman Voice Treatment on speech and voice characteristics of patients with Parkinsonian plus syndromes

 

POPULATION:  Parkinsonian plus syndromes

 

MODALITY TARGETED:  expressive

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED:  Intensity (loudness), pitch, pitch variation, duration

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  Intelligibility, articulation, vital capacity, structural/functional changes in speech/voice mechanism

 

DOSAGE: 1 hour sessions; 4 times a week; 4 weeks

 

ADMINISTRATOR:  SLP

 

STIMULI:   auditory (including taping of P for feedback), visual

 

GOAL ATTACK STRATEGY:   not clear

 

MAJOR COMPONENTS:  (cites sources with more complete explanation of the intervention)

 

Techniques:  vocal isometric exercises (vocal fold closure), deep and frequent breathing during speaking (respiratory support), “thinking loud” (respiratory), support), “speaking on top of the breath” (respiratory support), auditory feedback, visual feedback, vocalizing/speaking with loud background noise

 

Activities in Typical Session:

  •  multiple sustained productions of /a/ with deep breathing and appropriate posture

  •  P’s producing maximal and minimal fo during sustained phonation

  •  breathing exercises with visual biofeedback

  •  speech tasks with deep breathing and appropriate posture

  •  P’s producing maximal and minimal fo during speech tasks

 

DEPENDENT VARIABLE(S)/OUTCOME(S): 

  OUTCOME #1:  Intensity of sustained vowels  

  OUTCOME #2:  Maximum duration of sustained vowels  

  OUTCOME #3:  Mean fo of sustained vowels 

  OUTCOME #4:  Intensity during reading and speaking (conversation)

  OUTCOME #5:  Mean fo during reading and speaking (conversation)

  OUTCOME #6:  fo  variability during reading and speaking (conversation) 

  OUTCOME #7:  Single word intelligibility 

  OUTCOME #8:  Overall intelligibility 

  OUTCOME #9:  Loudness  

  OUTCOME #10: Monotonicity

  OUTCOME #11:  Imprecise articulation (slurring)

  OUTCOME #12:  Forced vital capacity 

  OUTCOME #13: Videostroboscopic evaluation

 

 

 

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