Pennington et al. (2010)

EBP THERAPY ANALYSIS

Treatment Groups

 

SOURCE:  Pennington, L., Miller, N., Robson, S., & Steen, N. (2010). Intensive speech and language therapy for children with cerebral palsy: A systems approach. Developmental Medicine and Child  Neurology, 52, 337-344.

 

REVIEWER(S):  pmh

 

DATE:  11.05.13

ASSIGNED GRADE FOR OVERALL QUALITY:  C (Highest possible grade is C+ due to the experimental design.)

 

TAKE AWAY:  This investigation provides initial, limited support of the effectiveness of a systems approach to treating dysarthria in English adolescents with cerebral palsy. Selected aspects of prosody (loudness, rate, pause) were used for outcomes concerned with intelligibility and P perceptions of the effectiveness of the intervention. Follow-up testing indicated that improvements were maintained for at least 6 weeks.

 

1.  What type of evidence was identified?

                                                                                                           

a.  What was the type of evidence?  Prospective, Single Group with Pre- and Post-Testing  

b.  What was the level of support associated with the type of evidence?  Level = C+

                                                                                                           

2.  Group membership determination:

a.  If there were groups, were participants randomly assigned to groups?  N/A

b.  If there were groups and participants were not randomly assigned to groups, were members of groups carefully matched?  N/A

3.  Was administration of intervention status concealed?

a.  from participants?  No

b.  from clinicians?  No

c.  from analyzers?  Yes

 

4.  Were the groups adequately described?  No

a.         How many participants were involved in the study?

•  total # of participant:  16

•  # of groups:  1

b.  The following variables were controlled:

INCLUSION CRITERIA

•  age:  11-19 years (actual Ps 12-18 years, mean 14 years)

•  diagnosis:  cerebral palsy with dysarthria

•  severity of dysarthria:  moderate to severe

EXCLUSION CRITERIA

•  hearing:  bilateral hearing impairment exceeding 50 dB hearing loss

•  vision:  severe impairment unable to be corrected with glasses

•  cognitive skills:  profound impairment

The following variables were described:

•  age:

•  gender:  7m, 9f

•  functioning on Gross Motor Function Classification system

bilateral  15/16

  – I: 1

  – II: 4

  – III: 2

  – IV: 5

  – V: 4

c.   Were the groups similar before intervention began?  Not Applicable , there was only one group.

d.  Were the communication problems adequately described?

•  disorder type:  dysarthria

•  type of dysarthria:

– spastic 9

– dyskinetic 2

– mixed 4

– Worster-Drought 1

 

5.  Was membership in groups maintained throughout the study?

a.  Did each of the groups maintain at least 80% of their original members?  Yes

b.  Were data from outliers removed from the study?  No  

 

6.   Were the groups controlled acceptably?  NA. There was only one group.   

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

•  OUTCOME #1:  Improved single word intelligibility on the Children’s Speech Intelligibility Measure

•  OUTCOME #2:  Improved intelligibility of connected speech in 60 second narratives elicited during sequence picture describing tasks.

•  OUTCOME #3:  Positive P rating of effectiveness of the intervention on a 3 point scale

b.  All the outcome measures were subjective.

c.  None of the outcome measures were objective.

 

8.  Were reliability measures provided?

a.  Interobserver for analyzers?  Yes

 

•  OUTCOME #1:  Improved single word intelligibility on the Children’s Speech Intelligibility Measure—   familiar listeners’ mean r = 0.53, CI = 0.44-0.69 (95%); unfamiliar listeners’ mean r = 0.83, CI = 0.78-0.87 (95%)

•  OUTCOME #2:  Improved intelligibility of connected speech in 60 second narratives elicited during sequence picture describing tasks— familiar listeners’ mean r = 0.31, CI = 0.15-0.47 (95%); unfamiliar listeners’ mean r =  0.67. CI =  0.59-0.75 (95%)

•  OUTCOME #3:  Positive P rating of effectiveness of the intervention on a 3 point scale—reliability data not provided

 

b.  Intraobserver for analyzers?  No 

c.  Treatment fidelity for clinicians? No

 

9.  What were the results of the statistical (inferential) testing?

a.  PRE VS POST TREATMENT

•  OUTCOME #1:  Improved single word intelligibility on the Children’s Speech Intelligibility Measure

     –  familiar listeners: for pre vs post intervention scores, post were significantly better (0.001)

     –  unfamiliar listeners:  post was better than pre but it is not clear if the difference reached significance (p = ≤ 0.05)

 

•  OUTCOME #2:  Improved intelligibility of connected speech in 60 second narratives elicited during sequence picture describing tasks.

     –  familiar listeners:  for pre vs post intervention scores, post score were significantly different (0.003)

     –  unfamiliar listeners:  post was better than pre but it is not clear if the difference reaches significance (p = ≤ 0.05)

 

•  OUTCOME #3:  Positive P rating of effectiveness of the intervention on a 3-point scale—This outcome was not subjected to analysis using inferential statistics.  Descriptively:

     –  14/16 Ps rated the intervention as definitely helpful

–  2/16 Ps rated the intervention as partially helpful

     – 16/16 would recommend to a friend

b.  What was the statistical test used to determine significance?  t-test,  ANOVA

c.  Were confidence interval (CI) provided?  Yes

d.  CI for Outcomes:

 

–  OUTCOME #1:  Improved single word intelligibility on the Children’s Speech Intelligibility Measure

     –  familiar listeners: estimated change 14.7% (95% CI 9.8-19.5%)

     –  unfamiliar listeners:  estimated change 15% (95% CI 11.73-18.17%)

 

•  OUTCOME #2:  Improved intelligibility of connected speech in 60 second narratives elicited during sequence picture describing tasks.

     –  familiar listeners: estimated change 12.1% (95% CI 4.3-20%)

     –  unfamiliar listeners:  estimated change 15.9% (95% CI 11.8-20%)

                                   

10.  What is the clinical significance?  Not provided

 

11.  Were maintenance data reported?  Yes. Outcomes #1 and #2 were measured 2 times:  one and six weeks after intervention. There were no significant differences between the one and six week measures. Therefore, changes were maintained for at least 6 weeks

 

12.  Were generalization data reported?  No

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate the effectiveness of a systems approach which focuses on respiration, phonation, and rate for treating dysarthria speech of adolescents with cerebral palsy.

POPULATION:  dysarthria associated with cerebral palsy (adolescents)

 

MODALITY TARGETED:  production

ELEMENTS OF PROSODY USED AS INTERVENTION:  rate, loudness, pausing

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  intelligibility*

* = significant improvement noted

 

OTHER TARGETS:  P perception of effectiveness**

** = this outcome was not subjected to inferential statistical analysis; however, descriptive statistics suggest the Ps perceieved marked improvement

DOSAGE:  3 sessions per week, 6 weeks, 35-40 minute sessions; did not receive other speech-language therapy during this time.  However, Ps did not receive the same amount of therapy.

 

ADMINISTRATOR:  SLP

 

STIMULI:  auditory

 

MAJOR COMPONENTS:

•  Focus of intervention:

–  respiration

–  phonation

–  rate of speech

–  phrase length (syllables per breath)

•  Intervention principles:

–  high intensity practice

–  presentation of randomly ordered stimuli within the targeted task

–  initial frequent feedback

–  fading of feedback

–  C’s provision of cues or prompts to elicit specific skills targeted in intervention

Phase1:

– coordinate phonation and initiation of sustained vowels

Phase 2:

– coordinate phonation and spoken language

–  tasks

•  slow speech with vocalization maintained across phrase

•  maintain breath throughout phrase

•  pause for breath at syntactically appropriate boundaries

 

–  Hierarchical exercises (to move to next step must be successful 90% of trials in which P controlled phonation/respiration over the whole target)

Step 1: 10 common phrases

Step 2:  single words

Step 3:  sentences

Step 4:  connected speech

 

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