Fox & Boliek (2012)

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.

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