Dworkin et al. (1988)

EBP THERAPY ANALYSIS for

Single Subject Designs

 

SOURCE:  Dworkin, J., Abkarian, G. G., & Johns, D. F. (1988). Apraxia of speech:  The effectiveness of a treatment regimen. Journal of Speech and Hearing Disorders, 53, 280-294.

 

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

 

DATE:  2009

ASSIGNED OVERALL GRADE:  A-

TAKE AWAY:  This single subject experimental design provides good support for the effectiveness of a lengthy program of treatment designed to speech production with an adult diagnosed with apraxia.

                                                                                                                       

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?  Single Subject Experimental Design with Specific Client – Multiple Baseline

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?

a.  How many participants were involved in the study?  1

b.  The following characteristics were described:

•  age:  57 years

•  gender:  f                                       

•  language:  English speaker but was not her 1st language; emigrated to US at 16 years from Sweden

•  etiology:  aneurysm of left middle cerebral artery

•  post onset:  16 months

•  previous speech-language therapy:  yes, while in hospital and 6 months as outpatient

c.  Were the communication problems adequately described?  Yes

•  The disorder type was  moderate apraxia of speech with no dysarthria or aphasia, oral apraxia

•  Other aspects of communication

–  “slow, groping, effortful”  (p. 282) articulation

–  false starts

–  hesitations

–  repetitions (sounds, syllable, words)

–  inconsistent articulatory errors

–  metathesis

–  transpositions

–  cluster reduction

–  word fluency was in the low range of WNL

                                                                                                                       

5.  Was membership in treatment maintained throughout the study? Not applicable

 

                

5a.  If there was more than one participant, did at least 80% of the participants remain in the study?  Yes ___        No  _____        Not  applicable  _x__

5b.  Were any data removed from the study?  Yes ___        No  _x___

Explain:

 

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?  No

e.  Were different treatment counterbalanced or randomized? Not Applicable 

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were:

TREATMENT

  OUTCOME #1:  To raise and lower the tongue tip to the beat of a metronome

  OUTCOME #2:  To produce target syllables to the beat of a metronome (Alternate Motion Rate, AMR)

  OUTCOME #3:  To produce targeted words presented on index cards to the beat of a metronome

OUTCOME #4: (a)  To read aloud 5 word sentences to the beat of a metronome without concern for appropriate stress patterns (b) To read aloud a sentence in response to C queries with appropriate sentence stress.

CONTEXTUAL SPEECH/GENERALIZATION

  OUTCOME #5:  To improve ratings of speech normalcy of connected speech

b.  All the outcomes were subjective.

c.  None the outcomes were objective.

d.  Overall interobserver reliability was noted.

e.  Data supporting  overall reliability–

•  Interobserver eliability was reported to be 90% or greater for all outcome measures.

 

8.  Results:

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

b.  The quality of improvement for each of the outcomes was

TREATMENT

OUTCOME #1:  To raise and lower the tongue tip to the beat of a metronome— Strong

OUTCOME #2:  To produce target syllables to the beat of a metronome— Strong

OUTCOME #3:  To produce targeted words presented on index cards to the beat of a metronome— Strong

OUTCOME #4: (a)  To read aloud 5 word sentences to the beat of a metronome without concern for appropriate stress patterns (b) To read aloud a sentence in response to C queries with appropriate sentence stress.–  Strong (for a and b)

CONTEXTUAL SPEECH/GENERALIZATION

OUTCOME #5:  To improve ratings of speech normalcy of connected speech— Limited

9.  Description of baseline:

a.  Were baseline data provided?  Yes

•  The number of data points for each dependent variable/outcome was TREATMENT

OUTCOME #1:  To raise and lower the tongue tip to the beat of a metronome— 4

OUTCOME #2:  To produce target syllables to the beat of a metronome— 8

OUTCOME #3:  To produce targeted words presented on index cards to the beat of a metronome–4

OUTCOME #4: (a)  To read aloud 5 word sentences to the beat of a metronome without concern for appropriate stress patterns (b) To read aloud a sentence in response to C queries with appropriate sentence stress.—4 for (a) and (b)

CONTEXTUAL SPEECH/GENERALIZATION

OUTCOME #5:  To improve ratings of speech normalcy of connected speech—4

 

b.  Was baseline low and stable? (The numbers should match the numbers in item 7a.)

TREATMENT

OUTCOME #1:  To raise and lower the tongue tip to the beat of a metronome—bow and moderately unstable

OUTCOME #2:  To produce target syllables to the beat of a metronome (alternate motion rates) – low and stable

OUTCOME #3:  To produce targeted words presented on index cards to the beat of a metronome—low and stable

OUTCOME #4: (a)  To read aloud 5 word sentences to the beat of a metronome without concern for appropriate stress patterns (b) To read aloud a sentence in response to C queries with appropriate sentence stress—(a) low and stable; (b) low and moderately unstable

CONTEXTUAL SPEECH/GENERALIZATION

OUTCOME #5:  To improve ratings of speech normalcy of connected speech–moderate and stable

c.  What was the percentage of nonoverlapping data (PND)?  (The numbers should match the numbers in item 7a.  Note if there are insufficient data to calculate PND.)

•  PND measures were calculated by a reviewer (pmh).

  TREATMENT

OUTCOME #1:  To raise and lower the tongue tip to the beat of a metronome—PND = 100%

OUTCOME #2:  To produce target syllables to the beat of a metronome (Alternate motion rates) —PND = 97%

OUTCOME #3:  To produce targeted words presented on index cards to the beat of a metronome—PND = 100%

OUTCOME #4: (a)  To read aloud 5 word sentences to the beat of a metronome without concern for appropriate stress patterns (b) To read aloud a sentence in response to C queries with appropriate sentence stress—PND = 100%  for both (a) and (b)

CONTEXTUAL SPEECH/GENERALIZATION

OUTCOME #5:  To improve ratings of speech normalcy of connected speech —PND = 75%

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

•  Interpretation of PND (Schlosser & Wendt, 2008):

•  PND measures were calculated by a reviewer (pmh).

  TREATMENT

OUTCOME #1:  To raise and lower the tongue tip to the beat of a metronome—highly effective

OUTCOME #2:  To produce target syllables to the beat of a metronome (Alternate motion rates) —highly effective

OUTCOME #3:  To produce targeted words presented on index cards to the beat of a metronome—highly effective

OUTCOME #4: (a)  To read aloud 5 word sentences to the beat of a metronome without concern for appropriate stress patterns (b) To read aloud a sentence in response to C queries with appropriate sentence stress—highly effective for both (a) and (b)

CONTEXTUAL SPEECH/GENERALIZATION

OUTCOME #5:  To improve ratings of speech normalcy of connected speech —fairly effective

 

 

 

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. Maintenance data were reported for Outcomes #1, 2, and 3. According to Figure 7 (p. 288) all treated behaviors achieved 100% accuracy during maintenance testing. The investigators did not report maintenance data for Outcome #4, the final treated outcome, because the data collection strategy involved measuring the completed outcome every 12 sessions after meeting criterion.

 

13.  Were generalization data reported? Yes. Outcome #5, an untreated outcome, was measured to determine if behaviors targeted in therapy carried over to connected speech. The results of the investigation revealed that treatment did generalize to connected speech. In addition, because the investigators measured baselines for as yet untreated behaviors throughout treatment, they were able to make claims about generalization of learned behaviors to untreated behavior. The investigators determined that outcomes did not improve until they were targeted in therapy.

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION:  __A-____

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate the effectiveness of an intervention designed to improve the speech of an adult with apraxia.

POPULATION:  speech and oral apraxia without dysarthria or aphasia

 

MODALITY TARGETED:  expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED:  contrastive stress, terminal contour

 

ELEMENTS OF PROSODY USED AS INTERVENTION: contrastive stress, rhythm

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: articulatory accuracy in words, sentences, and connected speech

 

OTHER TARGETS:  tongue tip motion, alternate motion rate (AMR)

DOSAGE:  144 sessions, 3 times a week, 30  minutes

 

ADMINISTRATOR:  SLP

 

STIMULI:  auditory, visual, bite block

GOAL ATTACK STRATEGY:  vertical

 

MAJOR COMPONENTS:

•  Criterion =  ≥ 90% correct responses on treatment task for 4 consecutive sessions

•  OUTCOME #1:  To raise and lower the tongue tip to the beat of a metronome

–  Step 1:  P and C sit in front of a mirror.

–  Step 2:  C assists P in the placement of a bite block on the right side of P’s mouth

–  Step 3:  C sets metronome to 12 beats per minute.

–  Step 4:  C directs P to move raise tongue to the alveolar ridge (1 beat) and then lower it  (next beat). The tongue should remain in position (raised or lowered) for about 5 seconds.

–  Step 5:  After each minute of exercise, P rests for 30 seconds.

–  Step 6:  When P reaches criterion, C directs P to move raise tongue to the alveolar ridge (1 beat) and then lower it  (next beat) with the metronome set at 60 beats per minutes.  (P still rests for 30 seconds after 1 minute of exercise.)

OUTCOME #2:  To produce target syllables to the beat of a metronome (AMR)

–  Step 1:  C sets metronome to 15 beats per minute.

–  Step 2:  With the target being “puh-tuh-kuh” C directs P to produce “puh” with 1st  beat of the metronome. “tuh” with the 2nd  beat, and “kuh” with the 3rd beat.  All three productions had to be accurate and free of apraxic symptoms such as impression, sequencing problems.

–  Step 3: Throughout the exercise, C provides P with 30 seconds of rest following 1 minute of the work.

–  Step 4:  C increases the metronome rate to 60 beats per minutes and continues to direct P to produce the individual elements of the “puh-tuh-kuh” sequence to the beat of the metronome.

–  Step 4:  C increases the metronome rate to 120 beats per minutes and continues to direct P to produce the individual elements of the “puh-tuh-kuh” sequence to the beat of the metronome.

–  Step 5:  C maintains the metronome rate to 120 beats per minutes but changes the target to for P to “kuh-puh-tuh.”

OUTCOME #3:  To produce targeted words presented on index cards to the beat of a metronome

Target:  9 words (listed in article’s Appendix A);  words must be produced with accurate articulation and the absence of apractic symptoms (imprecise articulation, sequencing errors); a trial is one attempt at one word

–  Step 1:  C sets the metronome to 60 beats per minute.

–  Step 2:  C directs P to read bisyllable words from index cards at the rate of one syllable per beat.

–  Step 3:  C directs P to read trisyllable words from index cards at the rate of one syllable per beat.

–  Step 4:  C directs P to read multisyllable words from index cards at the rate of one syllable per beat.

–  Step 5:  C sets the metronome to 120 beats per minute

–  Step 6:  C directs P to read bisyllable words from index cards at the rate of one syllable per beat.

–  Step 7:  C directs P to read trisyllable words from index cards at the rate of one syllable per beat.

–  Step 8:  C directs P to read multisyllable words from index cards at the rate of one syllable per beat.

OUTCOME #4a:  To read aloud 5-word sentences to the beat of a metronome without concern for appropriate stress and intonation patterns

Target = 5 sentences with 5 words each (see Appendix A in article) sentences must be produced with accurate articulation and the absence of apractic symptoms (imprecise articulation, sequencing errors); the sentences were treated individually [e.g, the 1st sentence was treated to criterion (≤ 90% correct for 4 sessions) and then the 2nd sentence was treated].

–  Step 1:  C sets the metronome at 60 beats per minute.

–  Step 2:  C directs P to read a sentence at the rate of 1 word per beat.

–  Step 3:  C provides 30 seconds of rest following 20 trials.

–  Step 4:  When P reaches criterion for the 5th sentence, C changes to metronome to 120 beats per minute.

–  Step 5:  C directs P to read a sentence at the rate of 1 word per beat and provides 30 seconds of rest following 20 trials.

OUTCOME #4b:  To read aloud a sentence in response to C queries with appropriate sentence stress and intonation.

Target = same 5 sentences as in Oucome #4a.  The criteria were same but an addition criterion was added—P needed to place primary stress on the most important word (new information) in the sentence during a question/answer task. Again, the sentences were treated individually [e.g, the 1st sentence was treated to criterion (≤ 90% correct for 4 sessions) and then the 2nd sentence was treated].

Note: The metronome is not used for this outcome.  The example which follow are from page 284.

–  Step 1:  C reads aloud the target sentence (e.g., The box contained 3 sweaters) with a neutral stress and declarative intonation/falling terminal contour.

–  Step 2:  C produces the target sentence with a (a) change on word (e.g., sweater is changed to hat) and (b) questioning intonation/rising terminal contour.  For example, “The box contained 3 hats?

–  Step 3:  P produces the target sentence using a declarative intonation and stress on the word that C had incorrectly produced (e.g., “sweater.”)

–  Step 4:  An entire trial consisted of P presenting sentence in which the “error” word progressively moves earlier in the sentence.  For example:

C:  The box contained 3 hats?

P:  No, the box contained 3 sweaters.

C:  The box contained 4 sweaters?

P:  No, the box contained 3 sweaters.

C:  The bag contained 3 sweaters?

P:  The box contained 3 sweaters.

–  Step 5:  After the 1st target sentence is presented in a trial, C moves to the 2nd sentence, and so forth.

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