Samuelsson (2010)

August 29, 2013

Single Subject Research

Source: Samuelsson, C. (2010) Prosody intervention for children. In H. Roddam & J. Skeat (eds.) Embedding evidence-based practice in speech and language therapy: International examples (pp. 189-194). Chichester, UK: Wiley-Blackwell .

 

Reviewer(s):   pmh

 

Date:  8.16.13

 

Overall Assigned Grade:  C (The brevity of chapter resulted in the omission of much information.)

Level of Evidence:  A-

 

Take Away:  This very brief chapter consists of a description of a strategy for decision-making about prosodic intervention in a context of having little or no evidence supporting a particular approach. A brief presentation of a single subject experimental design study was provided illustrating the process.

 

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?  Yes

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

b.  The following characteristics were described

•  age:  4 years

•  gender:  m

•  expressive language:  WNL

•  receptive language:  WNL

•  Language:  Swedish

c.  Were the communication problems adequately described?  Yes          

•  The disorder types were  phonological disorder, prosodic disorder

•  Other aspects of communication were

–  problems with prosodic production at the word level, phase level, and discourse level on an instrument designed to assess Swedish prosody.

  –  prosodic perception was stronger than prosodic production 

                                                                                                                       

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

a.  If there was more than one participant, did at least 80% of the participants remain in the study?  Not  applicable

b.  Were any data removed from the study?  No. Data were not removed. However, due to the brief nature of the chapter, only summary statements were made. No specific data were reported.

 

6.  Did the design include appropriate controls?  Unclear. This was only a brief presentation.

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?  No

d.  Was the data collection continuous?  No

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

  OUTCOME #1:  To improve prosody at the word level on a specific assessment instrument

  OUTCOME #2:  To improve prosody at the phrase level on a specific assessment instrument

  OUTCOME #3:  To improve prosody at the discourse level on a specific assessment instrument

b.  All of the outcomes were subjective.

c.  None of the outcomes were objective.

d.  None of the outcomes were associated with reliability data.

 

8.  Results:

a.  Did the target behavior improve when it was treated?  Yes. No specific data were reported. The characterizations were descriptive and provided in the prose of the chapter.

b.  The  overall quality of improvement was

OUTCOME #1:  To improve prosody at the word level on a specific assessment instrument  Effective

OUTCOME #2:  To improve prosody at the phrase level on a specific assessment instrument  Effective

OUTCOME #3:  To improve prosody at the discourse level on a specific assessment instrument  Slight improvement

9.  Description of baseline:

 

a.  Were baseline data provided? Yes

  OUTCOME #1:  To improve prosody at the word level on a specific assessment instrument:  3 times over 9 weeks

OUTCOME #2:  To improve prosody at the phrase level on a specific assessment instrument:  3 times over 9 weeks

OUTCOME #3:  To improve prosody at the discourse level on a specific assessment instrument:  3 times over 9 weeks

(continue numbering as needed)

 b.  Was baseline low and stable?

NOTE:  Data were not provided, but in the prose, the investigator described nature of baseline data.  The investigator described the prosodic problems as stable over the baseline period.

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. Follow up administration of the assessment instrument revealed that the results were stable with some slight improvement.

 

13.  Were generalization data reported?  No. However, the assessment instrument involved word, phrase, and discourse contexts.

 

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

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate the effectiveness of a prosodic intervention designed to improve the prosodic skills of a child who speaks Swedish

POPULATION:  phonological disorder, prosodic disorder (Swedish)

 

MODALITY TARGETED:  comprehension and production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: lexical stress, phrasal stress, intonation

DOSAGE:  6 one-hour sessions plus homework

 

ADMINISTRATOR:  SLP and family

 

STIMULI:  auditory and visual

 

MAJOR COMPONENTS:

•  Basic Goal:  improve prosody at the word, phase, and discourse level

•  Intermediate Goal:  to produce prosodic contrasts at the word, phrase, and discourse level

WORD LEVEL

•  This was the main focus of intervention.

•  Intervention involved perception and production. Because P had stronger perception, perception was used to facilitate production.

•  C presented P with minimal pairs in Swedish. The two Swedish words differed in pitch direction (tonal word accent) and/or stress.  (The investigator provided illustrations of Swedish minimal pairs.)

PHRASAL LEVEL

•  Target: phrasal stress and intonation of real and nonsense sentence

•  P imitated C’s production of a real or nonsense sentences

DISCOURSE LEVEL
•  C recorded P’s discourse.

•  P listened to the recordings focusing on prosody.

•  It is assumed P discussed his production of prosody.

 

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Fox & Boliek (2012)

August 25, 2013

EBP THERAPY ANALYSIS for

Single Subject Designs

 

SOURCE:  Fox, C. M., & Boliek, C. A. (2012).  Intensive voice treatment (LVST LOUD)  for children with spastic cerebral palsy with dysarthria. Journal of Speech-Language-Hearing Research, 55, 930-945.

 

REVIEWER(S):  pmh

 

DATE:  8.03.13

ASSIGNED OVERALL GRADE:  B+  (a well done paper but limited participant and program description reduces grade)

 

TAKE AWAY:  This investigation, which is supported by a single-subject design, provides initial support the application of Lee Silverman Voice Treatment (LSVT) for children with cerebral palsy. The results indicate that measures of the children’s loudness, pitch variability, and voice quality improved following 16 sessions of LSVT LOUD.

 

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?  Variable.  Perceptual analyses were blinded.

 

4.  Were the participants adequately described?  No, I would have liked information about language and cognitive skills.

a.  How many participants were involved in the study?  10 (5 with CP, 4 received tx; 5 TD)

b.  The following characteristics were controlled:

•  diagnosis:  dysathria secondary to cerebral palsy             

•  hearing:  WNL or aided to normal limits

•  vocal mechanism:  no vocal pathology

•  follow directions:  able to follow directions associated with intervention tasks

•  medications:  stable

•  exclusionary criteria:  severe velopharyngeal incompetence, speech mechanism structural problems, additional speech disorders

–  The following characteristics were described:

•  age:  5-7 years

•  gender:  2f, 5m                                                                              

c.  Were the communication problems adequately described? No, excellent description of speech characteristics but no description of language.

•  diagnosis:  dysarthria secondary to cerebral palsy

•  type of dysarthria:  4 spastic, 1 mixed spastic/ataxic

•  severity of dysarthria:  mild-moderate (1), moderate (3), severe (1)

•  prosodic problems:  loudness problems (5), pitch problems (1), intonation (2), rate (3), general prosodic problems  (1)

•  voice quality problems:  4

•  articulation problems:  5

                                                                                                                       

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?  Yes. The investigators removed a small amount of data from analysis due to technical recording issues.

 

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_x__     No  ___

c.  Did probes/intervention data include trained data?  No

d.  Was the data collection continuous?  No

e.  Were different treatment counterbalanced or randomized? Yes

fIf “6e” was yes, was it counterbalanced or randomized?  Randomized

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

  OUTCOME #1:  Improved perception of overall loudness in imitated speech

  OUTCOME #2:  Improved perception of loudness variability in imitated speech

  OUTCOME #3:  Improved perception of overall pitch in imitated speech

  OUTCOME #4:  Improved perception of pitch variability in imitated speech

  OUTCOME #5:  Improved perception of voice quality in imitated speech

  OUTCOME #6:  Improved perception of articulatory precision in imitated speech

OUTCOME #7:  Increased maximum phonation of “ah”

  OUTCOME #8:  Increase fo range of vowels

  OUTCOME #9Increase sound pressure level (SPL) of vowels

OUTCOME #10:  Increased harmonics-to-noise ratio of vowels

  OUTCOME #11:  Increased SPL of 9 imitated sentences

  OUTCOME #12:  Increased fo range of 9 imitated sentences

OUTCOME #13:  Improved scores on a parental rating checklist

b.  The outcomes that are subjective are

  OUTCOME #1:  Improved perception of overall loudness in imitated speech

  OUTCOME #2:  Improved perception of loudness variability in imitated speech

  OUTCOME #3:  Improved perception of overall pitch in imitated speech

  OUTCOME #4:  Improved perception of pitch variability in imitated speech

  OUTCOME #5:  Improved perception of voice quality in imitated speech

  OUTCOME #6:  Improved perception of articulatory precision in imitated speech

  OUTCOME #13:  Improved scores on a parental rating checklist

 

c.  The outcomes that are objective are

OUTCOME #7:  Increased maximum phonation of “ah”

  OUTCOME #8:  Increase fo range of vowels

  OUTCOME #9Increase sound pressure level (SPL) of vowels

OUTCOME #10:  Increased harmonics-to-noise ratio of vowels

  OUTCOME #11:  Increased SPL of 9 imitated sentences

  OUTCOME #12:  Increased fo range of 9 imitated sentences

                                                       

d.  All the outcome measures are associated with some form of reliability data.

e.  The data supporting reliability of each outcome measure is provided below.

•  For the perceptual outcomes (Outcomes #1-6) , a panel of 7 judges rated the samples of Ps while listening over external speakers. Although no interrater reliability data were provided, the ratings were averaged for each outcome for each P. Overall intrarater reliability ranged from 74% to 89%.

•  For the acoustic outcomes (Outcomes #7-12), 3 judges independently inspected visual representations of the acoustic outcomes.  •  Intrarater reliability ranged from 0.68 to 0.90. One P was not available for reliability measurement. Interrater reliability

OUTCOME #7:  Increased maximum phonation of “ah”  r = .99

OUTCOME #8:  Increase fo range of vowels  r = .99

OUTCOME #9:  Increase sound pressure level (SPL) of vowels  r = .99

OUTCOME #10:  Increased harmonics-to-noise ratio of vowels  r = .94

OUTCOME #11:  Increased SPL of 9 imitated sentences r = .99

OUTCOME #12:  Increased fo range of 9 imitated sentences  r = .90

•  For Parental Rating (Outcome #13), intrarater reliability ranged from .68 to .90

 

8.  Results:

a.  Did the target behavior improve when it was treated?  Inconsistent.  Performance improved for many but not all the possible outcomes.

b.   For each of the outcomes,  the overall quality of improvement was

    OUTCOME #1:  Improved perception of overall loudness in imitated speech:

•  Baseline to Posttest: of the 4Ps who received treatment 4 were significantly better at post, the difference was moderate for 3 and strong for 1; for the one child who did not receive treatment there was no progress. 

•  Baseline to Follow up: of the 4Ps who received treatment 1 P was  significantly better at follow up, the difference was  moderate; for the one child who did not receive treatment there was no significant  progress. 

OUTCOME #2:  Improved perception of loudness variability in imitated speech

•  Baseline to Posttest: of the 4Ps who received treatment  3 were significantly better at post, the difference was strong for 1P and moderate for 2; for the one child who did not receive treatment  there was no significant improvement

•  Baseline to Follow up: of the 4Ps who received treatment  3  were significantly better at follow up, the difference was moderate for all; for the one child who did not receive treatment there was no significant improvement

OUTCOME #3:  Improved perception of overall pitch in imitated speech

•  Baseline to Posttest: of the 4Ps who received treatment  2 were significantly better at post, the difference was moderate for both ; for the one child who did not receive treatment there was no significant improvement.

•  Baseline to Followup: of the 4Ps who received treatment none were significantly better at post; for the one child who did not receive treatment, there was no significant improvement. 

OUTCOME #4:  Improved perception of pitch variability in imitated speech

•  Baseline to Posttest: of the 4Ps who received treatment  4 were significantly better at post, the difference was  moderate; for the one child who did not receive treatment  there was no significant improvement

•  Baseline to Follow up: of the 4Ps who received treatment 1 significantly better at follow up, the difference was moderate; 1 was significantly worse;  for the one child who did not receive treatment there was no significant improvement.

OUTCOME #5:  Improved perception of voice quality in imitated speech

•  Baseline to Posttest: of the 4Ps who received treatment 4 were significantly better at post, the difference was strong (1), moderate (2), and limited (1) ; for the one child who did not receive treatment, there was no significant improvement 

•  Baseline to Follow up: of the 4Ps who received treatment  3 were significantly better at follow up, the difference was  moderate for all; for the one child who did not receive treatment, did not improve significantly.

OUTCOME #6:  Improved perception of articulatory precision in imitated speech

•  Baseline to Posttest: of the 4Ps who received treatment 3 were significantly better at post, the difference was moderate; for the one child who did not receive treatment, there was no significant improvement.

•  Baseline to Follow up: of the 4Ps who received treatment none were significantly better at follow up; for the one child who did not receive treatment, there was no significant improvement. 

OUTCOME #7:  Increased maximum phonation of “ah”

•  Baseline to Posttest: of the 4Ps who received treatment 2 were significantly better at post, the difference was moderate (1) and strong (1)  ; for the one child who did not receive treatment, outcome was significantly poorer for post.

•  Baseline to Follow up: of the 4Ps who received treatment  3 were significantly better at follow up, the difference was strong (3); for the one child who did not receive treatment, there was no significant improvement.

OUTCOME #8:  Increase fo range of vowels

•  Baseline to Posttest: of the 4Ps who received treatment  3 were significantly better at post, the difference was strong for all; for the one child who did not receive treatment, the outcome was significantly poorer at post. 

•  Baseline to Follow up: of the 4Ps who received treatment  2  were significantly better at follow up, the difference was strong (1) and moderate (1); for the one child who did not receive treatment, there was no significant Improvement. 

OUTCOME #9:  Increased sound pressure level (SPL) of vowels

•  Baseline to Posttest: of the 4Ps who received treatment 1 was significantly better at post, the difference was strong ; for the one child who did not receive treatment, there was no significant improvement. 

•  Baseline to Follow up: of the 4Ps who received treatment 2 were significantly better at follow up, the difference was strong (1) and ineffective (1); for the one child who did not receive treatment, there was not significant improvement.

OUTCOME #10:  Increased harmonics-to-noise ratio of vowels

•  Baseline to Posttest: of the 4Ps who received treatment none were significantly better at post,; for the one child who did not receive treatment, there was no significant change.

•  Baseline to Follow up: of the 4Ps who received treatment 1 was significantly better at follow up, the difference was strong; for the one child who did not receive treatment, there was no significant improvement. 

OUTCOME #11:  Increased SPL of 9 imitated sentences

•  Baseline to Posttest: of the 4Ps who received treatment 2 were significantly better at post, the difference was strong (1) and moderate (1); for the one child who did not receive treatment, there was no significant improvement. 

•  Baseline to Follow up: of the 4Ps who received treatment 2 were significantly better at follow up, the difference was strong (1) and moderate (1); for the one child who did not receive treatment, there was no significant improvement.    

OUTCOME #12:  Increased fo range of 9 imitated sentences

•  Baseline to Posttest: of the 4Ps who received treatment none were significantly better at post; for the one child who did not receive treatment, there was no significant improvement. 

•  Baseline to Follow up: of the 4Ps who received treatment 1 was significantly better at follow up, the difference was strong; for the one child who did not receive treatment, there was no significant improvement. 

OUTCOME #13:  Improved scores on a parental rating checklist  (descriptive data only)

•  Baseline to Posttest: of the 4Ps who received treatment all improved in loudness. Each of the Ps also improved in a variety of voice quality parameters.

•  Baseline to Follow up: of the 4Ps who received treatment, there was no or limited maintenance.

9.  Description of baseline:

a.  Were baseline data provided?

•  Outcomes #1-12:  number of baselines varied from 4 to 8 for Ps receiving treatment

•  Outcome #13:  one data collection point

b.  Was baseline low and stable?  Not applicable, only averaged data were published.

c.  What was the percentage of nonoverlapping data (PND)?  NA

 

10.  What was the magnitude of the treatment effect?

  OUTCOME #1:  Improved perception of overall loudness in imitated speech  NA

  OUTCOME #2:  Improved perception of loudness variability in imitated speech  NA

OUTCOME #3:  Improved perception of overall pitch in imitated speech  NA

OUTCOME #4:  Improved perception of pitch variability in imitated speech  NA

OUTCOME #5:  Improved perception of voice quality in imitated speech  NA

  OUTCOME #6:  Improved perception of articulatory precision in imitated speech  NA

OUTCOME #7:  Increased maximum phonation of “ah”

•  magnitude of effect:  .3- 1.9 (posttest); .7- 10.1 (follow up)

•  measure calculated:  ES

•  interpretation:  ineffective to strong

  OUTCOME #8:  Increase fo range of vowels

•  magnitude of effect:  -1.3 – 5.6 (post); 1.4 – 3.8 (follow up)

•  measure calculated:  ES

•  interpretation:   ineffective to strong

OUTCOME #9:  Increase sound pressure level (SPL) of vowels

•  magnitude of effect:  0.0 – 5.5 (post); 0.0 – 8.7 (follow up)

•  measure calculated:  ES 

•  interpretation:  ineffective to strong

OUTCOME #10:  Increased harmonics-to-noise ratio of vowels

•  magnitude of effect: 0.0 -0.7 (post); .8- 2.0 (follow up)

•  measure calculated:  ES   

•  interpretation:  moderate – strong

OUTCOME #11:  Increased SPL of 9 imitated sentences

•  magnitude of effect: -0.4 – 4.7 (post);  .4 – 5.5 (follow up)

•  measure calculated:   ES

•  interpretation:  contraindicated to strong 

OUTCOME #12:  Increased fo range of 9 imitated sentences

•  magnitude of effect:  .6 – 2.0 (post); .6 – 7.3 (follow up)

•  measure calculated:  ES

•  interpretation: moderate to strong

OUTCOME #13:  Improved scores on a parental rating checklist  NA

 

11.  Was information about treatment fidelity adequate?  Not Provided

 

12.  Were maintenance data reported?  Yes. For the most part, the gains were not maintained 6 weeks after the termination of therapy. Follow-up measures were administered 6 weeks after treatment. The results varied. Some participants maintained progress and others did not.

 

13.  Were generalization data reported? Yes.  Parental ratings could be considered generalization data. The behaviors that were most likely to see improvement were loudness and voice quality parameters.

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION:  B+

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate an adaption of Lee Silverman Voice Treatment (LSVT LOUD) with children with dysarthria associated with cerebral palsy

POPULATION:  children with dysarthria secondary to cerebral palsy

 

MODALITY TARGETED:  expression

 

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

 

ELEMENTS OF PROSODY USED AS INTERVENTION:  loudness

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  articulation, voice quality, interaction/pragmatics, intelligibility

DOSAGE:  16 individual treatment session (4 times a week, 4 weeks); 1 hour sessions

 

ADMINISTRATOR:  SLP

 

STIMULI: auditory

 

MAJOR COMPONENTS:

•  LSVT is a well-documented intervention for individuals with Parkinson’s disease. Competent providers should enroll in LSVT training classes. Accordingly, the description of the intervention would not be sufficient to allow for replication.

•  LVST involves encouraging Ps to use healthy, louder voices to improve the communication of speakers with neurological impairments. The view is that it is beneficial to focus on only one parameter (loudness).

•  LSVT consists of intensive therapy, for a relatively short period of time. The treatment steps are clearly delineated and discrete.

HOMEWORK

•  Homework was assigned after each session.

–  On treatment days one (5-10 minute) homework session was assigned. On nontreatment days, two (10-15 minute) homework sessions were assigned.

–  P also was directed to carry out one activity in which he/she used the loud voice with someone in the daily environment (e.g., saying “Good morning” to the school bus driver).

–  C checked each day with P to discuss the success of the environmental carry over activity.

•  Treatment sessions, which were conducted at home, were divided into 2 parts:

1ST PART OF SESSIONS

–  Maximum duration activities in which vowels were vocalized for as long as possible.

–  Frequency range activities in which P was encouraged to produce maximum pitch ranges on vocalizations.

–  Five repetitions each of 10 phrases/sentences. These phrases/sentences were developed with the family and were relevant to activities of daily living.

2nd PART OF SESSIONS

–  CONTENT:  Hierarchical progression of production of sentences from single words to conversation OR for a lower functioning child verbalizations progressing from structured (naming) to unstructured (playing games requiring spontaneous verbalizations) contexts.

–  TASK:

•  P produces at least 15 repetitions of each item

•  C encourages loud productions and increased vocal effort as well as sensory feedback by asking questions.


Freeman & Garstecki (1973)

August 13, 2013

Single Subject Designs

 

SOURCE: Freeman, S. R., & Garstecki, D. C. (1973). Child-directed therapy for nonorganic voice disorder: A case study. Language, Speech, and Hearing Services in Schools, 4, 8-12.

 

REVIEWER(S): pmh  

 

DATE:  7.30.13

ASSIGNED OVERALL GRADE:   D-   (Due to the level of evidence, D+ was the highest possible grade for this source.)

 

TAKE AWAY:  This investigation provides initial, limited support for the use of a child-directed intervention for the improvement of pitch (level, variability) and  loudness in an 11 year-old with a nonorganic voice problem.

 

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?  Variable, the listener groups were blind.  However, some of the outcome data were derived from participant and clinician data.                                        

 

4.  Were the participants adequately described?  No

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

b.  The following characteristics were described:

•  List characteristics controlled:

•  List characteristics described:

•  age:  11 years

•  gender:  f                                       

•  previous therapy:  none

c.  Were the communication problems adequately described? Yes

•  The disorder type was  nonorganic voice disorder

•  Other aspects of communication that were described include

–  pitch:  low  for CA

–  voice quality:  hoarse

–  inflection:  limited

                                                                                                                       

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

a.  If there was more than one participant, did at least 80% of the participants remain in the study?  Not applicable

b.  Were any data removed from the study? 

 

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

a.  Were baseline/preintervention data collected on all behaviors?  No

b.  Did probes/intervention data include untrained data?  No

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

d.  Was the data collection continuous?  Yes

6e.  Were different treatment counterbalanced or randomized?  Not Applicable 

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

  OUTCOME #1:  Improved self- and clinician ratings of overall voice in a read audiorecorded sample.

  OUTCOME #2:  Improved ratings of overall voice in a read audiorecorded sample by groups of listeners

b.  All of the outcomes were subjective.

c.  None of the outcomes were objective.

d.  The investigator provided present reliability data for  Outcome #1.

e.  The data supporting reliability for the outcome measure was

  OUTCOME #1: Improved self- and clinician ratings of overall voice in a read audiorecorded sample.

     The investigators charted the ratings by P and C.  The trends in ratings were similar but C consistently rated herself higher than P.

 

8.  Results:

a.  Did the target behaviors improve when they were treated?  Yes

b.  The overall quality of improvement was

  OUTCOME #1:  Improved self- and clinician ratings of overall voice in a read audiorecorded sample.  P’s rating stong; C’s rating moderate

OUTCOME #2:  Improved ratings of overall voice in a read audiorecorded sample by groups of listeners  Unclear (insufficient data provided) but the last session was rated as significantly better than the last session.

9.  Description of baseline:

a.  Were baseline data provided?  No

 

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

 

13.  Were generalization data reported?  No 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION:  __D-_

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To determine if a child-directed approach to voice intervention focusing on inflection, intensity, pitch, and quality would result in improvements.

POPULATION:  child, nonorganic voice disorder

MODALITY TARGETED:  expression

ELEMENTS/FUNCTIONS OF PROSODY TARGETED:  pitch (level and variability), intonation (overall contour), loudness

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  voice quality, overall vocal behavior

DOSAGE:  nine weeks, one meeting per week

ADMINISTRATOR:  SLP 

STIMULI:  auditory, written material

MAJOR COMPONENTS:

TECHNIQUES:  reading aloud, verbal feedback, self-monitoring, metalinguistics (explanations), positive reinforcement

STEP 1:  C defines and explains the parameter that will be the focus of intervention:  inflection (pitch variability, overall intonation contour), pitch (level), intensity (loudness), voice quality.  [Terms in parentheses are terms from the Prosodic Teaching Model (PTM, Hargrove & McGarr, 1994).  For the remainder of the investigators’ terminology will be used.]

STEP 2:  P practices producing and varying the parameters from Step #1: inflection, pitch, intensity, and quality.

STEP 3:  P reads and audiotapes a passage selected by C.  After each reading, P evaluates her audiotaped performance.  C provides positive reinforcement as appropriate.

STEP 4:  At the end of the session, P and C independently evaluate C’s overall performance on a 10-point scale and identify which of the 4 parameters (inflection, pitch, intensity, and quality) should be worked on in the following session.  (The investigator provided sample forms for the evaluation and outcome selection.)


Blake et al. (2013)

August 7, 2013

SECONDARY REVIEW (SNR) CRITIQUE

Source:  Blake, M. L., Frymark, T., & Venedictov, R. (2013). An evidence-based systematic review on communication treatment for individuals with right hemisphere brain damage. American Journal of Speech-Language Pathology, 22, 146-160.

 

Reviewer(s): pmh

 

Date:  7.25.13

 

Overall Assigned Grade:  A-

 

Level of Evidence:   A+

 

Take Away: This systematic review focused on 4 outcomes for treating individuals with right hemisphere brain damage. Only one of the outcomes was concerned with prosody and only that outcome is reviewed here. This is a well-executed systematic review but a major limitation is the limited number of qualifying sources. Nevertheless, two approaches to teaching the production of sentence with prosody that are appropriate for designated affective states were identified.

 

What type of secondary review?  Narrative Systematic Review

 

1.  Were the results valid?

a.  Was the review based on a clinically sound clinical question?  Yes

b.  Did the reviewers clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)?  Yes

c.  The authors noted that they reviewed the following resources:

•  hand searches

•  electronic databases

•  references from identified literature

•  searched authors identified in conference proceedings, conference proceedings, dissertations, and grey literature 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?  Yes

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?  Yes

j.  Did the reviewers or review teams rate the sources independently?  Yes

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?  Yes. Differences were resolved by consensus.

n.  Were assessments of sources sufficiently reliable?  Unclear/Variable

o.  Was the information provided sufficient for the reader to undertake a replication?  Yes

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

q.  Were there a sufficient number of sources?  No

2.  Description of outcome measures:

The outcomes

NOTE:  Only Outcome #1 will be discussed because it is the only one concerned with prosody.

•  Outcome #1:  Changes in prosody associated with sentence or discourse level communication intervention

•  Outcome #2:  Changes in receptive language associated with sentence or discourse level communication intervention

•  Outcome #3:  Changes in expressive language associated with sentence or discourse level communication intervention

•  Outcome #4:  Changes in pragmatic language associated with sentence or discourse level communication intervention

 

3.  Description of results: 

NOTE:  Only Outcome #1 will be discussed because it is the only one concerned with prosody.

a.  What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size?

•  standardized mean difference (d) with confidence intervals

b.  Summarize overall findings of the secondary review:

Only one source qualified for review (Rosenbek et al., 2006). The review revealed that both interventions (imitative and cognitive-linguistic) yielded improvements in affective prosody. The differences between the two interventions was small. The reviewers called for additional research in improving of prosody of speakers with right hemisphere brain damage.

c.  Were the results precise?  Unclear/Variable  _x__ 

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?  Yes 

e.  Were the results of individual studies clearly displayed/presented? Unclear/Variable

f.  For the most part, were the results similar from source to source?  Not applicable, there was only one source.

g.  Were the results in the same direction?  Not applicable, there was only one source.

h.  Did a forest plot indicate homogeneity?  Not applicable, there was only one source.

i.  Was heterogeneity of results explored?  Not applicable, there was only one source.

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

k.  Were negative outcomes noted  No

                                                                                                                   

4.  Were maintenance data reported?  No

 

SUMMARY OF INTERVENTION

DESCRIPTION OF PROCEDURE #1—Rosenbek’s 6 Step Continuum—Imitation

Target:  To produce emotional prosody at the sentence level

Procedure:  At the first step, C models sentences with appropriate prosody for P and directs him/her to imitate. C gradually removes cues until P produces sentences in response to question with appropriate emotional prosody.

 

Evidence Supporting Procedure #1— Overall, Ps improved following at least one of the interventions (imitation or cognitive/linguistic).

 

Evidence Contraindicating Procedure #1—(provide title)— Although there were not statistically significant differences, Imitative intervention was slightly less effective  (d = 0.24) than Cognitive/Linguistic. Blake et al. noted the CI crossed null making interpretation difficult.

 

DESCRIPTION OF PROCEDURE #2— Rosenbek’s 6 Step Continuum—Cognitive/Linguistic

Target:  To produce emotional prosody at the sentence level

Procedure:  C presents cues associated with affective states (prosodic features, emotional states, and pictures representing emotional states) and gradually reduces support until P produces sentences in which prosodic behaviors are appropriate for the signified affect.

 

Evidence Supporting Procedure #2— Overall, Ps improved following at least one of the interventions (imitation or cognitive/linguistic)

 

Evidence Contraindicating Procedure #2— Although there were not statistically significant differences, Cognitive-Linguistic intervention was slightly more effective  (d = 0.24) than Imitative.  Blake et al. noted the CI crossed null making interpretation difficult.


Rosenbek et al. (1974)

August 4, 2013

 

EBP THERAPY ANALYSIS for

Single Subject Designs

 

SOURCE:  Rosenbek, J., Hansen, R., Baughman, C. H., & Lemme, M. (1974). Treatment of developmental apraxia of speech: A case study. Language, Speech, and Hearing Services in Schools, 5, 13-22.

 

REVIEWER(S):  pmh

 

DATE:  7.21.13

ASSIGNED OVERALL GRADE:  D+  (this is the highest grade possible because of the case study design)

 

TAKE AWAY:  This case study provides limited evidence that an intervention program for childhood apraxia of speech that incorporated selected aspects of prosody (i.e., rate, stress) has potential for improving speech.

 

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 – Program Description with Case Illustration

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?  Variable

 

4.  Were the participants adequately described?  Yes

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

b.  The following characteristics were  described

•  age: 9 years

•  gender:  f

•  cognitive skills:  WNL but severe academic problems

•  hearing:   WNL

•  expressive language:  impaired

•  receptive language:  WNL

•  MLU:  sentences average 2-3 words                

•  educational level of participant: in second grade

•  prior therapy:  6 years

•  auditory discrimination:  WNL

c.  Were the communication problems adequately described?  Yes

•  The disorder types were  oral apraxia and developmental apraxia of speech (childhood apraxia of speech)

•  Other aspects of communication that were described:

–  intelligibility:  poor

–  articulation:  poor performance on Templin-Darley Test of Articulation; better in isolated words than in connected speech

–  stimulability:   most sounds were stimulable

–  expressive language:  sentences average 2-3 words; the following tended to be omitted:  articles, prepositions, verb forms

–  motor speech skills:  articulatory groping; difficulty initiating speech

–  auditory memory:  some depression but insufficient to explain communication problems

–  expressive-receptive language gap:  present

                                                                                                                       

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

 

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

a.  Were baseline/preintervention data collected on all behaviors?  No, data were not collected for ALL the outcomes but it was collected for one outcome–/r/ production (Outcome #1).

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

c.  Did probes/intervention data include trained data?  No

d.  Was the data collection continuous?  Yes, for Outcome #1

e.  Were different treatment counterbalanced or randomized? Not Applicable

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

  OUTCOME #1:  To increase the number of correct productions of /r/ in a 20 item speaking task.

  OUTCOME #2:  To increase intelligibility rating in spontaneous conversation

b.  All the outcomes were subjective.

c.  None of the outcomes were objective.

d.  None of the outcome measures were accompanied by reliability data that are reliable:  none

 

8.  Results:

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

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

   OUTCOME #1:  To increase the number of correct productions of /r/ in a 20 item speaking task– strong

OUTCOME #2:  To increase intelligibility rating in spontaneous conversation– moderate

9.  Description of baseline:

a.  Were baseline data provided? Inconsistent, the first data point for Outcome #1 could be considered a baseline because the probe was administered before the sessions as were probes before each session.  For Outcome #2, spontaneous samples only were elicited before the first session, midway through the 22 sessions, and at the end of treatment. 

•  The number of data points for Outcome #1 was

    OUTCOME #1:  To increase the number of correct productions of /r/ in a 20 item speaking task— 1

b.  Was baseline low and stable?

  OUTCOME #1:  To increase the number of correct productions of /r/ in a 20 item speaking task—NA, only one baseline session.

c.  What was the percentage of nonoverlapping data (PND)?

NOTE:  The reviewer calculated PND

  OUTCOME #1:  To increase the number of correct productions of /r/ in a 20 item speaking task—95%

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

OUTCOME #1:  To increase the number of correct productions of /r/ in a 20 item speaking task—highly 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?  No

13.  Were generalization data reported? Yes. The second outcome was concerned with the intelligibility of speech in conversation and can be considered to be indicative of generalization. There was a

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION:  __D+_____

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To describe procedures for treating childhood apraxia of speech and provide an illustrative case study.

POPULATION:  childhood apraxia of speech

 

MODALITY TARGETED:  expression

 

ELEMENTS OF PROSODY USED AS INTERVENTION:  rate, prolongation, pause, sentence stress

 

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  /r/ production, intelligibility

DOSAGE:  22 sessions over 3 months

 

ADMINISTRATOR:  SLP

 

STIMULI:  auditory, gesture, visual/written cues,

 

MAJOR COMPONENTS:

STEP 1:  In spaced drills, C taught P compensatory and facilitating behaviors such as

•  reduce speaking rate by prolonging vowels and continuant consonants

•  pause between syllables of multisyllabic words

•  add a schwa to consonant clusters

•  produce utterances with equal and even stress

A.  P produced target utterances using compensations. The utterances were controlled by type and complexity

•  type: sentences with carrier phrases and a target word (e.g., I see a ___), functional phrases (e.g., phone numbers, addresses), lists that were functional in school (e.g., days of the week, counting)

•  complexity:  utterances with ordered with the following considerations—

–  visible sounds before nonvisible sounds

–  distance between sounds in words with sounds closer to one another being targeted prior to words with sounds further apart.

•  C provided tangible reinforcement for correct attempts.

B.  C guided P’s arm to swing in a semicircle for each syllable of the targeted utterance (alternate motions could be using a finger to trace a pattern or squeezing a bean bag.)

C.  C provided P with written cues to encourage the production of the facilitators.  For example, with the utterance written on a card, the C included a symbol (e.g., U) under each syllable. The same symbol was used to cue the addition of the schwa between the sounds in a consonant cluster in a word such as ‘blue.’  (NOTE:  The investigators reported that this appeared to be very helpful.)

D.  C recorded P’s responses and worked with P to establish the skill of self-monitoring.

STEP 2:  Accurate production of sounds from the /r/ family.

— C reinforced P for correct behaviors.

— Order of targets was

•  monosyllable words with or without consonant clusters  (from 2nd grade reader)

•  multisyllabic words  (from 2nd grade reader)

•  phrases and sentences (C created and from 2nd grade reader)

The following were the criteria for a correct response:

•  correct production of /r/

•  slow speaking rate

•  equal and even stress

•  addition of schwa to consonant clusters

A.  C presented written words or phrases containing /r/ with visual cues from P’s 2nd grade reader.

B.  C first requested P to imitate target words/phrases and then to produce them spontaneously. C modeled and required P to accompany productions with swinging arm movements or with other rhythmic movements.

STEP 3:  Application of “chew” procedures

A.  To facilitate slow rate production, P directed C to produce target sentences as if she were chewing like a cow.

NOTE:  The stress compensations involved atypical stress patterns (equal and even stress).