Leon et al. (2005)


Single Subject Designs


SOURCE:   Leon. S. A., Rosenbek, J. C., Crucian, G. P., Hieber, B., Holiway, B., Rodrigues, A. D., Ketterson, T. U., Ciampitti, M. Z., Freshwater, S., Heilman, K., & Gonza;ez-Rothi, L. (2005). Active treatments for aprosodia secondary to right hemisphere stroke.  Journal of Rehabilitation Research and Development, 42 (1), 93-102.


REVIEWER(S):  Jessica Jones (Minnesota State University, Mankato),  Amy Anderson (Minnesota State University, Mankato), pmh


DATE:   2009



TAKE AWAY:  This investigation provides support for two approaches to treating expressive aprosodia associated with right hemisphere strokes. Both approaches resulted in marked changes in the outcome measure. The Imitative approach was more likely to result in improvement for two of the Ps and the Cognitive-Linguistic approach was superior for the third P. There is a considerable body of literature that provides strong support for these two approaches to treating expressive aprosodia.




1.  The focus of the research was Clinical Research


2.  What type of evidence was identified?                              

a.  What type of single subject design was used? Single Subject Experimental Design with Specific Client: ABAC        

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

Level =  A-                                                       


3.  Was phase of treatment concealed?

a.  from participants?  No                             

b.  from clinicians?  No                                 

c.  from data analyzers?  No.                       


4.  Were the participants adequately described?  Yes

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

b.  The following characteristics were described

•  age:  49- 57

•  gender:  2f, 1m                                                        

•  educational level of participant:  2 HS, 1 RN

•  Post-onset:  4-9 months

•  Site of lesion:  2 right hemisphere +; 1 images not available but exhibited left hemiplegia

•  Medications:  varied

 Native Language:  English

•  left hemipariesis:  2 yes, 1 weakness only

•  previous speech-language therapy:  1- 2½ months

c.  Were the communication problems adequately described? Yes

•  The disorder type was   right hemisphere stroke, expressive aprosodia

•  The following aspects of communication were described:

–  receptive aprosodia:  all 3,  mild


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?  Yes

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

b.  Did probes/intervention data include untrained data?  Yes

c.  Did probes/intervention data include trained data?  Yes

d.  Was the data collection continuous?  Yes

e.  Were different treatment counterbalanced or randomized? Yes

f.   The investigators randomized assignment to counterbalanced administrations of the two intervention approaches (Imitative and Cognitive-Linguistic).


7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcome was  % of read sentences correctly representing a targeted affect

b.  Was the outcome subjective? Yes                                          

c.  Was the outcome objective?  No                                              

d.  Was reliability data provided for the outcome:  Yes       

e.  The data supporting reliability of the outcome measure was Intraobserver = .75; interobserver = .79


8.  Results:

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

b.  The overall quality of improvement was moderate to strong for the Imitative intervention; limited to moderate for Cognitive-Linguistic intervention

9.  Description of baseline:

a.  Were baseline data provided?  Yes, 8 data points for each baseline

b.  Was baseline low (or high, as appropriate) and stable? The first baseline for all Ps was low and stable.  The second baseline, which occurred before the administration of the second intervention approach,  was high and stable for 1P and moderate and stable for 2Ps.   (This complicated some of the interpretation of the second intervention.)

c.  What was the percentage of nonoverlapping data (PND)? These data were calculated by the reviewers from the tables provided in the article.

•  P1 – Imitation =  60%      ; Cognitive-Linguistic =  30%

•  P2 – Imitation =  55%      ; Cognitive-Linguistic =  10%

•  P3 – Imitation =  73%      ; Cognitive-Linguistic =  95%

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

•  P1 – Imitation =  questionable; Cognitive-Linguistic =  ineffective

•  P2 – Imitation =  questionable; Cognitive-Linguistic =  ineffective

•  P3 – Imitation =  fairly; Cognitive-Linguistic =  highly


10.  What was the magnitude of the treatment effect?


•  magnitude of effect:  Imitative =  3.68; Cognitive-Linguistic = 2.76

•  measure calculated:  Individual effect size; formula provided on page 99.

•  interpretation:  Imitative =  large; Cognitive-Linguistic =  large


•  magnitude of effect:  Imitative =  2.52; Cognitive-Linguistic = 0.660

•  measure calculated:  Individual effect size; formula provided on page 99.

•  interpretation:  Imitative =  large; Cognitive-Linguistic = moderate


•  magnitude of effect:  Imitative =  2.01; Cognitive-Linguistic = 11.51

•  measure calculated:  Individual effect size; formula provided on page 99.

•  interpretation:  Imitative =  large; Cognitive-Linguistic =  large


11.  Was information about treatment fidelity adequate?  No


12.  Were maintenance data reported?  No


13.  Were generalization data reported? Yes. Pre and Post Intervention scores on the Florida Affect Battery were described.  All Ps improved on the expressive portion and 2Ps improved on the receptive portion.







PURPOSE:  To compare the effectiveness of two interventions (Imitative and Cognitive-Linguistic approaches) for expressive aprosodia.

POPULATION:  right hemisphere damage; expressive aprosodia





DOSAGE:  each intervention consisted of 20 one-hour sessions administered over a month.




STIMULI: :   Imitative treatment: visual (cards with target sentences written on them). auditory, visual;  Cognitive-linguistic:  visual (cards with target sentences written on them, 4 cards describing the prosody of each emotion, 4 cards describing the facial expression associated with each emotion), auditory, visual.




•  The investigators notes indicated that a more thorough description of the intervention procedures were provided with the online version of this article.  I did not have access to the online version but see Rosenbek et al. (2006) for a more thorough description of the interventions.

•  There were 2 interventions:  Imitative and Cognitive-Linguistic.

•  Each P received both treatments.  The administrations were in a randomly determined order.  The approaches were separated by a second set of baseline sessions.

•  Both interventions comprised 6 steps with cueing moving from maximum to minimal throughout the steps.

•  In both interventions, C worked on one sentence at a time with the sentences moving through the 6 steps before moving onto the next sentence unless that sentence was discontinued for that session due to failure to progress. (See “Criteria” for additional information about discontinuation.)

•  Each session involved 9 sentences (3 exemplars each of happy, sad, and angry) which changed each session.


•  Imitative =  moved from replication of Cs model to independent production of a sentence with the targeted emotion.

•  Cognitive- Linguistic =  This was a metalinguistic task in which C provided P with information about the acoustic cues associated with the reading aloud of a sentence with the targeted emotion. As P moved through the steps, C reduced the amount of information provided to P.


•  To move from 1 step to the next, P produced 3 consecutive productions of the targeted sentence and affect.

•  If P did not reach criterion in 5 attempts, C moved to the previous step.

•  If P moved back two previous steps, the sentence was discontinued for the day.


NOTE:   The investigators noted that C had experience with evaluating affective prosody and was knowledgeable about the acoustic correlates of emotional states.  However, the investigators did not describe the specific acoustic correlates associated with the emotional states for this research.


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