Gilbert (2008)

January 31, 2014

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

 

NOTE:  Scroll about 1/3 of the way down to read the summary of the interventions.

 

SOURCE: Gilbert, J. (2008).  Teaching pronunciation using the prosody pyramid. New York: Cambridge University Press

http://www.cambridge.org/other_files/downloads/esl/booklets/Gilbert-Teaching-Pronunciation.pdf

 

Reviewer(s):  pmh

 

Date:  1.29.14

 

Overall Assigned Grade:  F  (Highest grade based on type of evidence is F.)

 

Level of Evidence:  F = Expert Opinion

 

Take Away:  This booklet highlights the Prosody Pyramid and its associated treatment procedures which are presented in Gilbert’s book Clear Speech (2005). Prosody Pyramid procedures were designed for second language learners; nevertheless, they have potential to guide SLPs in treating adolescents and adults with prosodic problems and, perhaps, those with intelligibility issues. Data were not provided to support the procedures.

https://clinicalprosody.wordpress.com/2014/01/31/gilbert-2008/

 

1.  Was there review of the literature supporting components of the intervention?  No

 

2.  Were the specific procedures/components of the intervention tied to the reviewed literature?  Yes, in several instances.

 

3.  Was the intervention based on clinically sound clinical procedures?  Yes

 

4.  Did the author(s) provide a rationale for components of the intervention?  Yes

5.  Description of outcome measures:

 

•  Outcome #1:  To use prosodic markers (pausing, falling terminal contour, phrasing, and syllable lengthening) to mark thought boundaries

 

•  Outcome #2:  To produce focus words (stress-sentence/phrase) within thought groups by manipulating rhythm, intonation,  and duration.

 

•  Outcome #3:  To stress the most appropriate syllable in multisyllable words.

 

 

6.  Was generalization addressed?  Yes. Outcomes, for the most part,  are concerned with achieving the targets in conversation.

 

7.  Was maintenance addressed?  No

 

 

SUMMARY OF INTERVENTION

 

NOTE:  The Prosody Pyramid is the basis for the interventions described in this section. The Prosody Pyramid approach focuses on rhythm/stress and intonation (or as the author labels it, melody) to improve pronunciation rather than focusing on individual speech sounds. Gilbert considers the thought group, which can range from a few words to a full sentence, to be the base of the Prosody Pyramid. Within each thought group, there is a single focus word that receives the most prominent stress. If the focus word contains more than one syllable, only one syllable can carry this primary stress. To insure intelligibility, this syllable must be clearly marked and produced.

     Gilbert is not a speech language pathologist and the booklet does not address clinical targets. I (pmh) have derived the interventions from the booklet, all errors are mine.

 

 

Description of Intervention #1—Marking thought boundaries.

 

TARGET:  To use prosodic markers (pausing, falling terminal contour, phrasing, and syllable lengthening) to mark thought boundaries.

 

TECHNIQUES:  listening, metalinguistics, reading aloud, drill/repetition, writing to dictation, imitation, gestural cues, choral speaking

 

STIMULI:  auditory, visual cues (read texts with and without visual cues such as pitch direction, lengthening cues), gestural cues

 

DOSAGE:  group work

 

ADMINISTRATOR:  ESL teacher

 

PROCEDURES: 

•  Using phone numbers and math problems, C orally (i.e., no visual cues) presents different groupings of numbers using pitch changes and pauses to mark the group boundaries.  (Gilbert provides examples.)

–  At first, Ps only listen to different patterns.

–  Then Ps imitate the pauses and pitch changes

–  In pairs, one P reads the numbers and the other writes them down using the targeted groupings.

 

•  The above exercise should be repeated with short sentences.

 

•  Ps in groups should listen to short lectures with scripts and mark thought groups.

 

•  Ps in groups listen to recorded speech and in small groups mark the thought groups. They should develop a rationale for why they selected their groupings.

 

•  Ps in groups should mark dialogues for thought groups and read them to the class.

 

•  Ps should record themselves in a conversation with someone outside the class. Later they should transcribe the conversation and analyze the marking of thought groups.

 

•  P reads sentences aloud being careful to link words within the though group together  (e.g., “The bussis late” for “the bus is late.”)

 

•  Gilbert recommends using gestures to facilitate the production of unstressed/deemphasized words such as contraction.  For example, she recommends that C assumes the role of a musical conductor in a class exercise in which half of the class as a chorus says “cannot” (two beats) and the other half says ‘can’t” (one beat) numerous times. This can be repeated several times with different contractions.

 

•  Gilbert recommends using writing dictation to practice any target. The C should give Ps only two chances to transcribe and then transcriptions should be compared to the target.

 

•  Gilbert provides thought group rules in the appendix.

 

RATIONALE/SUPPORT FOR INTERVENTION:  Logical

 

 

 

Description of Intervention #2— Focus words

 

TARGET:  To produce focus words (stress-sentence/phrase) within thought groups by manipulating rhythm, intonation, and duration.

 

TECHNIQUES:  metalinguistics; drill/repetition using carrier phrases, poetry, and chants; imitation; writing to dictation; choral speaking/singing; musical instruments; listening; reading aloud

 

STIMULI:  auditory, visual;

 

DOSAGE:  group work

 

ADMINISTRATOR:  ESL Teacher

 

PROCEDURES: 

•  P introduces the concepts of emphasis (for the focus word in the thought group) and de-emphasis (for other words in the thought group).

 

•  Cs practice producing emphasizing focus words and reducing non-focus words (particularly structure words).

–  C first repeats carrier phrase/template sentence at normal speaking rate several times.

–  C can vary loudness, visual cues (obscuring C’s face/mouth), voice quality (e.g., using a squeaky voice) to increase interest.

–  C directs Ps to imitate the carrier phrase/template sentence chorally several times.

–  C writes out carrier phrase/template sentence.

–  Ps break into small groups and continue the listening and producing exercises.

–  Initially, the carrier phrase/template sentence is short.  C gradually increases length and complexity to include more than a sentence.

 

•  C explains that sometimes structure words are emphasized. Ps listen to sentences with stressed structure words and discuss possible reasons for the stressing.

 

•  C works with Ps to analyze the carrier phrases/sentences and changes the models to emphasize and deemphasize words.

 

•  Hints for encouraging deemphasizing include:

– use of carrier phrase or template sentence (Where j’ah put the …..?)

– production of poetry or chants that contain reductions

 

•  Ps listen to C producing short sentences using pitch changes/intonation pattern to mark focus.  After listening to several repetitions of the same sentence and intonation pattern, Ps attempt to replicate the intonation using a kazoo.

 

•  In pairs, Ps read question-answer sentences to one another which have designated focus words marked by italics. One P reads the question the other reads the answer marking the appropriate focus word.

 

•  Gilbert recommends using writing dictation to practice any target. The C should give Ps only two chances to transcribe and then transcriptions should be compared to the target.

 

•  Gilbert provides focus rules in the appendix.

 

RATIONALE/SUPPORT FOR INTERVENTION:  Logical

 

 

Description of Intervention #3— Stress-lexical  (Gilbert notes this also is important for sentence/phrase stress.)

 

TARGETS:  To stress the most appropriate syllable in multisyllable words.

 

TECHNIQUES: metalinguistics, listening, reading, drill/repetition, writing to dictation,

 

STIMULI:  auditory,  motor/kinesthetic cues, visual cues,

 

DOSAGE:  group

 

ADMINISTRATOR:  ESL teacher

 

PROCEDURES: 

•  C explains the importance of the dictionary stress pattern of multisyllable words—that the stressed syllable will be the most important syllable when the word is the focus of the sentence/phrase. Clear production of that syllable should aid intelligibility.

 

•  C explains that loudness increases, increased vowel duration and clarity, as well as changes in pitch level and direction can be used to signal stress/emphasis.

•  C presents information about each of the above features (i.e., loudness, vowel duration and clarity, pitch level and direction) independently.

•  C explains the following about vowel duration:

–  it is the most important feature for detecting stress/emphasis in English

 

•  Ps practice listening for vowel duration contrasts (increased duration of stress syllables and decreased duration of unstressed syllables) in multisyllable words.

 

•  C provides Ps with strong, heavy rubber bands and word lists of multisyllable words in which the vowel of the stressed syllable is highlighted.  Ps place the rubber bands on their hands and stretch their hands apart as they produce the stressed syllable of the multisyllable word.

 

•  C repeats the above activity but uses different motor movements (e.g., raising hands or eyebrows, standing taller, etc.) In addition, C solicits vocabulary items from Ps.

 

•  C explains the following about vowel clarity:

–  speakers should focus on clearly articulating stressed syllables

–  Figure 4 differentiates stressed, unstressed, and schwa vowels.

–  the standard for the production of unstressed syllables can be relaxed since in conversation they tend to be less fully articulated. Specifically, speakers should focus on when they can use schwa in place of the fully articulated vowel in unstressed contexts.

 

•  To facilitate vowel reductions, C produces words and Ps mark vowels that the C reduces to a schwa.

 

•  C teaches vowel sound production by

–  the differentiating “alphabet” vowels (i.e., long vowels),  “relative” vowels (i.e., short vowels), and schwa. Gilbert provides hints and illustrations for teaching the different vowels

–  Gilbert presents exercises for teaching vowel sounds

–  Gilbert presents rules for decoding vowels from English writing

•  C explains the following about changes in pitch level and direction:

– speakers have their own pitch patterns; deviations from that pattern can signal stress/emphasis.

– pitch changes signal new/important information

– if P has learned to identify the lengthened syllable, noting pitch changes should be easier.

 

•  Gilbert recommends using writing dictation to practice any target. The C should give Ps only two chances to transcribe and then transcriptions should be compared to the target.

 

RATIONALE/SUPPORT FOR INTERVENTION:  Logical

 

 

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Ramig et al. (2001)

January 14, 2014

EBP THERAPY ANALYSIS

Treatment Groups

 

NOTE:  To view intervention summary, scroll approximately 2/3 of the way down.

SOURCE:  Ramig, L. O., Sapir, S., Fox, C., & Countryman, S. (2001). Changes in vocal loudness following intensive voice treatment (LSVT®) in individuals with Parkinson’s disease: A comparison with untreated patients and normal age-matched controls.  Movement Disorders, 16, 79-83.

 

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

 

DATE:  11.30.13

ASSIGNED GRADE FOR OVERALL QUALITY:  B+  (Highest grade possible based on grade only A.)

 

TAKE AWAY:  Good evidence that Lee Silverman Voice Treatment (LSVT) results in increases in SPL for Ps with Parkinson’s disease (PD) that are sustained 6 months after intervention.

 

1.  What type of evidence was identified?

a.  What was the type of evidence? (bold the appropriate design)  Prospective, Randomized Group Design with Controls

                                                                                                           

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

                                                                                                           

2.  Group membership determination:

a.  If there were groups, were participants randomly assigned to groups?            Yes. For Parkinson’s disease (PD) groups, assignment to treatment and no treatment (delayed) groups was random. Assignment to the neurologically normal (NN), of course, was not random.

3.  Was administration of intervention status concealed?

a.  from participants?  No

b.  from clinicians?  No

c.  from analyzers?  No 

 

4.  Were the groups adequately described?  Yes

a.  How many participants were involved in the study?

•  total # of participants:  43  

•  # of groups:  3

•  # of participants in each group:  14, 15, 14

•  List names of groups:  PD-T (Parkinson’s disease-Treatment), PD-NT (Parkinson’s disease-No Treatment), NN (neurologically normal)

b.  The following variables were described:  

•  age:  PD-T: 67.9 ; PD-NT: 71.2  ; NN: 69.8  (no significant differences)

•  gender:  PD-T: 7m, 7f  ; PD-NT:, 7m, 8f ; NN: 7m. 7f

•  time since diagnosis:  PD-T: 8.6 years; PD-NT: 7.8 years; NN: NA (no significant difference)

•  medication:  all Ps with PD optimally medicated; medication stable throughout investigation

•  hearing:  adequate for all Ps

 

c.   Were the groups similar before intervention began?

Yes

                                                         

d.  Were the communication problems adequately described?  No

•  disorder type:  hypokinetic dysarthria associated with Parkinson’s disease

•  functional level

•  severity:   PD-T: majority in moderate range ; PD-NT: majority in moderate range; NN: NA (no significant difference)

 

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?  Yes

a.  Was there a no intervention group?

Yes. There were 2 nontreatment groups:  1 with PD (PD-NT); one neurologically normal (NN).

   

b.  Was there a foil intervention group? No 

c.  Was there a comparison group?  No 

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

OUTCOME #1:  Increase sound pressure level (SPL) in the vocalization of /a/

OUTCOME #2:  Increase SPL in the reading of the Rainbow Passage.

  OUTCOME #3:  Increase SPL during a monologue

  OUTCOME #4:  Increase SPL during a picture description task (Cookie Theft picture)

b.  None of the outcome measures were subjective.

 

c.  All of the outcome measures were objective.

 

8.  Were reliability measures provided?

                                                                                                             

a.  Interobserver for analyzers?  No 

 

b.  Intraobserver for analyzers?  No 

 

c.  Treatment fidelity for clinicians?  

 

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

                                                                                                             

PRE VS POST TREATMENT FOR ALL 3 GROUPS  (only significant outcomes are listed):

OUTCOME #1:  Increase sound pressure level (SPL) in the vocalization of /a/

PD-T only:

•  pre vs post testing for /a/ (p= 0.001)

•  pre vs 6 month follow-up testing for /a/ (p= 0.001)

OUTCOME #2:  Increase SPL in the reading of the Rainbow Passage.

•  pre vs post testing for reading  (p= 0.001)

•  pre vs 6 month follow up testing for reading  (p= 0.001)

OUTCOME #3:  Increase SPL during a monologue

•  pre vs post testing for  monologue (p = 0.001)

•  pre vs 6 month follow up testing for  monologue (p = 0.025)

OUTCOME #4:  Increase SPL during a picture description task (Cookie Theft picture)

•  pre vs post testing for picture description (p = 0.005)

•  pre vs 6 month testing for picture description (p = 0.025)

b.  What was the statistical test used to determine significance?  Could not find this information in the paper.

 

c.  Were confidence interval (CI) provided?  No

 

                                   

10.  What is the clinical significance?  Not provided

 

11.  Were maintenance data reported?  Yes. As can be seen in item #9, all the Outcomes that were significantly different from pre to post testing were also significantly different at the 6 month follow up testing. In addition, there were no significant differences between post testing and 6 month follow up testing for all outcomes, including those that were significantly different pre to post (see item #9).

 

12.  Were generalization data reported?  Not clear. Treatment procedures included vocalization, reading, and conversation. It is assumed conversation includes monologues and picture description. This might indicate that there was no generalization.  However, if there were  different reading passages, monologue content, and/or pictures for description in testing and intervention, generalization could be claimed.   

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  B+

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To compare differences in SLP changes in the following groups:  Ps with PD who were treated with LSVT (PN-T); Ps with PD who were not treated with LSVT (PD-NT); neurologically normal individuals (NN). This comparison allowed for claiming that changes following LSVT are NOT due to the placebo or Hawthorne effect (comparison of PD-T to PD-NT) and to typical fluctuations (PD-T versus NN).

POPULATION:  Parkinson’s disease (hypokinetic dysarthria)

 

MODALITY TARGETED:  expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness

DOSAGE:  4 one-hour sessions per week for 4 weeks

 

ADMINISTRATOR:  SLP  (administrators of LSVT should receive formal training from LSVT programs)

 

STIMULI:  auditory, visual

 

MAJOR COMPONENTS:

 •  Focus:  high/maximum effort loudness by P, maximize phonatory effectiveness by improving vocal fold adduction in a healthy manner (i.e., no vocal fold hyperadduction and/or strain).

•  P directs C to take deep breaths to obtain increased loudness levels

•  P teaches C to produce maximum duration  and pitch range for /a/

•  C reminds P to use maximum phonatory effort and to “think loud” while producing:

– sustained phonation

– reading

–  conversational speech


Gilsenan (2011)

January 9, 2014

SECONDARY REVIEW CRITIQUE

Source: Gilsenan, E. (2011). What are the effects of music therapy on the communication of children diagnosed with autism.  University of Western Ontario.

http://uwo.ca/fhs/csd/ebp/reviews/2011-12/Gilsenan.pdf

 

Reviewer(s): pmh

 

Date:  12.30.13

 

Overall Assigned Grade:  C+ (Highest possible grade was B.)

 

Level of Evidence:  B

 

Take Away:  This critical review critiques and summarizes 9 research articles concerned with the use of music therapy to improve the communication skills of children with autism. It is difficult to generalize the findings because of the diversity of procedures, dosages, and participants.  Nevertheless, as the result of music therapy children of varying ages and varying degrees of severity of autism improved on some communication variables including turn taking, joint attention, vocalization, verbal expression, producing phrases, performance on testing instruments, singing songs, initiation, imitation, interacting, pointing, academic achievement, and attention. Only gesturing did not respond to music therapy in at least one of the reviewed sources. The author of the critical review provided several recommendations including (1) consider using music therapy to facilitate verbal communication in nonverbal children, (2) low functioning children may benefit from a combination of speech therapy and music therapy, (3) child directed procedures appear to be facilitative, (4) children with echolalia may benefit from music therapy to facilitate communication development. In addition, clinicians should consider pairing tactile  (e.g., bells or drums) and visual (i.e., pictures/object representing targeted words) when using music to teach vocabulary.

 

What type of secondary review?  Narrative Systematic Review

 

1.  Were the results valid? Yes

a.  Was the review based on a clinically sound clinical question?  Yes, but it was implied, not explicitly stated.

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

c.  Authors noted that they reviewed the following resources:

•  internet based databases   x

•  references from identified literature   x

d.  Did the sources involve only English language publications?  Yes

e.  Did the sources include unpublished studies? Yes

f.  Was the time frame for the publication of the sources sufficient?  Unclear. This was not described.

g.  Did the reviewers identify the level of evidence of the sources? No,  but she did identify the design.

h.  Did the reviewers describe procedures used to evaluate the validity of each of the sources? No but it was clear that these was a strategy.

i.  Was there evidence that a specific, predetermined strategy was used to evaluate the sources?  No but it was clear that these was a strategy.

j.  Did the reviewers or review teams rate the sources independently? No. There was only one reviewer

k.  Were interrater reliability data provided?  Not applicable

l.  If the reviewers provided interrater reliability data, list them: Not applicable

m.  If there were no interrater reliability data, was an alternate means to insure reliability described?  Not applicable

n.  Were assessments of sources sufficiently reliable?  Not applicable

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 outcome measures associated with each of the sources are

•  Outcome #1:  To improve joint attention (initiation and eye contact during attention), turn taking, gesture  (Kim et al., 2008)

•  Outcome #2:  To improve verbal, nonverbal and social communication using CARS-B Childhood Autism Rating Scale- Brazil (Gattino et al., 2011)

•  Outcome #3:  To improve on a testing instrument concerned with semantics, phonology, pragmatics, and prosody (Lim, 2010)

•  Outcome #4:  To improve prelinguistic communication—eye contact, looking and pointing at a stimulus, peer engagement, imitation of talking or singing (O’Loughlin, 2000)

•  Outcome #5:  To improve type, quality, and frequency of joint attention; social behaviors; and challenging behaviors and the PDDBI- Pervasive Developmental Disorder Behavior Inventory ( (Reitman, 2005)

•  Outcome #6:  To improve overall expressive language using ADOS Autism Diagnostic Observation Scale  (Tindell, 2009)

•  Outcome #7:  To improve social and symbolic behaviors such as eye contact, initiation of communication, and symbolic play (Wimpory et al.,1995)

•  Outcome #8:  To improve gestural, verbal, and social communication on the Rossetti Speech and Language Scale (Yeou-Cheng et al., 2006)

•  Outcome #9:  To improve receptive imitative routines  (Stephens, 2008)

 

3.  Description of results:

 

a.  What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? The author noted effect size in one review but she was not specific.

b.  Summary of the findings of the secondary review:

The author’s critical review indicated that music therapy has the potential for improving the communication skills of children with autism. The most frequently reviewed procedures involved child-directed approaches to treating communication skills but clinician directed approaches also were reviewed. The author noted that readers should consider that only 9 sources were reviewed and the reviewed sources contained an overall small number of participants and a variety of procedures and outcomes. The positive results of each of the 9 reviewed sources are

•  Outcome #1:  To improve joint attention (initiation and eye contact during attention), turn taking, gesture on the PDDBI—PDD Behavior Inventory and ESCS– Early Social Communication Scales  (Kim et al., 2008)

  – play and music therapy yielded significant change (p = 0.01)

  – music therapy resulted in significantly more changes than play therapy on the ESCS

  –  the increase in the duration of eye contact, turn taking, joint attention with eye contact, and bids for joint attention was significantly more for music therapy than for play therapy

•  Outcome #2:  To improve verbal, nonverbal and social communication using CARS-B Childhood Autism Rating Scale- Brazil (Gattino et al., 2011)

  –  subtests of the CARS-B were significantly better for music therapy compared to a control group

•  Outcome #3:  To improve on a testing instrument concerned with semantics, phonology, pragmatics, and prosody (Lim, 2010)

  – music therapy and speech therapy showed significant improvement

  – no significant difference between music and speech therapy

•  Outcome #4:  To improve prelinguistic communication—eye contact, looking and pointing at a stimulus, peer engagement, imitation of talking or singing (O’Loughlin, 2000)

  1. the 1st P group attended group therapy involving singing while pointing to pictures 2 times a week for 5 weeks. Ps were reported to improve in the following skills although no statistical support was offered for the claim:

  –  increase in vocalizations

  –  increase in singing songs

  –  increase of imitation new sounds on request

  –  increase in phrases

  –  increase in attention

  –  increase in pointing

  –  increase in joint attention

  –  increase in turn taking

 

  2.  the 2nd P group attended therapy 5 times, 3 sessions were undefined language therapy (not clear if this was group or individual therapy) and 2 groups sessions involved singing while pointing to pictures. Ps  were reported to improve in the following skills:

  –  music therapy reported significant increases in eye contact (p = .023) and looking at the stimulus (p = .014)

 

  3.  for the 3rd  P group, the C presented 10 songs representing language concepts (not clear if this was group or individual therapy, dosage not specified). C presented the songs slowly and then the P and C sang the song in unison.

  – No significant differences were reported in the outcomes.

 

  4. for the 4th  P group, the C presented songs representing language concepts to small groups in 9 sessions over 5 weeks. C presented the songs slowly and then the Ps and C sang the song in unison.

  – No significant differences were  were reported in the outcomes.

 

•  Outcome #5:  To improve type, quality, and frequency of joint attention; social behaviors; and challenging behaviors and the  PDDBI- Pervasive Developmental Disorder Behavior Inventory (Reitman, 2005)

  –  improved joint attention on the PDDBI (p = 0.01)

  –  other changes on PDDBI did not reach significance

  –  significant improvement in videotaped joint attention behaviors

•  Outcome #6:  To improve overall expressive language using ADOS– Autism Diagnostic Observation Scale (Tindell, 2009)

  –  significant improvement on ADOS for both Precision Songs curriculum and the eclectic school curriculum (p = .0003)

•  Outcome #7:  To improve social and symbolic behaviors such as eye contact, initiation of communication, and symbolic play (Wimpory et al., 1995)

  –  Report of single subject experimental design provided descriptive data only.

  –  eye contact –increased at maintenance

  –  initiation-  increased after treatment and continued to increase at maintenance

  –  number of interactions- increased after treatment and continued to increase at maintenance

 

•  Outcome #8:  To improve gestural, verbal, and social communication on the Rossetti Speech and Language Scale   (Yeou-Cheng et al., 2006)

–  Claimed but did not provide evidence that interactive musical activities using verbal and tactile stimulation provided a better outcome

•  Outcome #9:  To improve receptive imitative routines  (Stephens, 2008)

  –  Claimed but did not provide evidence that musical social milieu teaching improved receptive imitative routines.  The behaviors that improved were

  1.  spontaneous imitation of action word pairs (3 of 4 Ps)

  2.  improved motor imitation only (1 of 4 Ps)

  3.  generalization imitation  (2 of 4 Ps)

  4.  new turn-taking behaviors (2 of 4 Ps)

  5.  more appropriate academic behaviors (2 of 4 Ps)

 

c.  Were the results precise?  Unclear, the author did not provide  precision data.

d.  If confidence intervals were provided in the sources, did the reviewers consider whether evaluations would have varied if the “true” value of metrics.

Unclear. the author did not provide CI data.

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

f.  For the most part, were the results similar from source to source?  Yes. There tended to be some improvement in some variables in each of the sources.

g.  Were the results in the same direction?  Yes

h.  Did a forest plot indicate homogeneity?  Not Applicable

i.  Was heterogeneity of results explored?  No

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

k.  Were negative outcomes noted?  Yes   

                                                                                                                   

4.  Were maintenance data reported?  No,for the most part. However, one of the sources (Wimpory et al., 2005) did assess follow-up 2 years after intervention. Eye contact and initiations were maintained and improved at follow-up.

 

SUMMARY OF INTERVENTION

 

Prosodic Targets:  overall prosody

Nonprosodic Targets:

•  expressive language

•  eye contact

•  gesture

•  initiation of communication

•  joint attention

•  nonverbal communication

•  performance on testing instruments

•  phonology

•  pragmatics,

•  prelinguistic communication

•  receptive imitative routines

•  semantics

•  social communication

•  symbolic behaviors

•  symbolic play

•  turn taking

•  verbal communication

Aspects of Prosody Used in Treatment of Nonprosodic Targets:   music (rhythm, intonation)

 

Description of Procedures and Supporting Data:

     Description of Source #1:  To improve joint attention (initiation and eye contact during attention), turn taking, gesture on the PDDBI—PDD Behavior Inventory and ESCS– Early Social Communication Scales  (Kim et al., 2008)

–  treatment involved Improvisational Music Therapy in which the music therapist follows the child’s interactions musically with the purpose of improving joint attention.

 

•  Evidence Supporting Source #1:

– play and music therapy yielded significant change (p = 0.01)

– music therapy resulted in significantly more changes than play therapy on the ESCS

–  the increase in the duration of eye contact, turn taking, joint attention with eye contact, and bids for joint attention was significantly more for music therapy than for play therapy

 

•  Evidence Contraindicating Source #1:

  –  small number of Ps

–  high mortality rate

–  poor interrater reliability for nonexperimenters on test instruments

–  tendency of review author to accept view that nonsignificant differences should be noted

 

     Description of Source #2:  To improve verbal, nonverbal and social communication using CARS-B Childhood Autism Rating Scale- Brazil (Gattino et al., 2011)

–  treatment involved Relational Music Therapy which is a child-centered intervention in which the music therapist shapes the P’s behaviors following the child’s actions.

•  Evidence Supporting Source #2

–  subtests of the CARS-B were significantly better for music therapy compared to a control group (not clear if all subtests were significantly different)

–  suggestion that music therapy is more effective with lower functioning children

•  Evidence Contraindicating Source #2

–  CARS-B is not an appropriate instrument for treatment outcome research

–  presentation of finding were not clear in the review

     Description of Source #3:  To improve on a testing instrument concerned with semantics, phonology, pragmatics, and prosody (Lim, 2010)

–  the music therapy involved P viewing 6 videos focusing on targeted words  (2 sessions a day for 3 days but almost double the time allotted to speech therapy)

–  the speech therapy involved the teaching of the same words as in music therapy but the procedures were not described (2 sessions a day for 3 days but almost 1/2 the time allotted to music therapy)

•  Evidence Supporting Source #3:

–  music therapy and speech therapy showed significant improvement

–  no significant difference between music and speech therapy

–  suggests that lower functioning children benefit more from music therapy than speech-language therapy

•  Evidence Contraindicating Procedure #3

–  dosage for music therapy and speech therapy were not equivalent.

–  testing instrument was nonstandard

–  tendency of review author to accept view that nonsignificant differences should be noted

–  presentation of findings were not clear in the review

 

    Description of Source #4– To improve prelinguistic communication—eye contact, looking and pointing at a stimulus, peer engagement, imitation of talking or singing (O’Loughlin, 2000)

– there were 4 treatments:

1.  Group #1 attended group therapy involving singing while pointing to pictures 2 times a week for 5 weeks.

2.  Group #2 attended therapy 5 times, 3 sessions were undefined language therapy (not clear if this was group or individual therapy) and 2 groups sessions involved singing while pointing to pictures.

  3.  For Group #3, the C presented 10 songs representing language concepts (not clear if this was group or individual therapy, dosage not specified). C presented the songs slowly and then the P and C sang the song in unison.

4.  For Group #4, the C presented songs representing language concepts to small groups in 9 sessions over 5 weeks. C presented the songs slowly and then the Ps and C sang the song in unison.

 

•  Evidence Supporting Source #4

1. the 1st P group attended group therapy involving singing while pointing to pictures 2 times a week for 5 weeks. Ps were reported to improve in the following skills although no statistical support was offered for the claim:

–  increase in vocalizations

–  increase in singing songs

–  increase of imitation new sounds on request

–  increase in phrases

–  increase in attention

–  increase in pointing

–  increase in joint attention

–  increase in turn taking

2.  the 2nd P group attended therapy 5 times, 3 sessions were undefined language therapy (not clear if this was group or individual therapy) and 2 groups sessions involved singing while pointing to pictures. Ps  were reported to improve in the following skills:

–  music therapy reported significant increases in eye contact (p = .023) and looking at the stimulus (p = .014)

 

Evidence Contraindicating Source #4

1.  For the 3rd P group, the C presented 10 songs representing language concepts (not clear if this was group or individual therapy, dosage not specified). C presented the songs slowly and then the P and C sang the song in unison.

– No significant differences were reported in the outcomes.

2.  For the 4th P group, the C presented songs representing language concepts to small groups in 9 sessions over 5 weeks. C presented the songs slowly and then the Ps and C sang the song in unison.

– No significant differences were reported in the outcomes.

  3.  Failure to define terms

4.  Tendency of review author to accept view that nonsignificant differences should be noted

 

     Description of Source #5—To improve type, quality, and frequency of joint attention; social behaviors; and challenging behaviors (Reitman, 2005)

–  Treatment involved eight 30-minute sessions administered 2 times a week.  The sessions included the following which were paired with picture stimuli:

1.  greeting song

2.  imitation task while seated

3.  playing of instruments

4.  gross motor imitation

5.  closing song

 

•  Evidence Supporting Source #5:

–  improved joint attention on the PDDBI (p = 0.01)

–  significant improvement in videotaped joint attention behaviors

–  blind evaluators

–  multiple assessments

 

•  Evidence Contraindicating Source #5:

  –  only one change on PDDBI reached significance

–  several reliability issues

–  small N

–  clarifications on the PDDBI

–  concerns about the videotaping procedures

–  tendency of Gilsenan to accept changes that do not reach significance as worth of reporting

 

     Description of Source #6— To improve overall expressive language using ADOS Autism Diagnostic Observation Scale  (Tindell, 2009)

–  The treatment involved the Precision Songs and an eclectic school curriculum.  Neither procedure was described.

 

•  Evidence Supporting Source #6:

–  significant improvement on ADOS for both Precision Songs curriculum and the eclectic school curriculum (p = .0003)

–  apparently the procedures were well defined in the original source

•  Evidence Contraindicating Source #6:

–  differences among the Ps

–  possible treatment fidelity and skill differences in teachers

–  number of teachers involved in the treatments

–  should have  used nonparametric tests for all statistical analyses

     Description of Source #7— To improve social and symbolic behaviors such as eye contact, initiation of communication, and symbolic play (Wimpory et al., 1995)

– Treatment involved the use of Music Interaction Therapy which is a child-centered intervention in which C responds to P’s action with live music to improve social interaction. Dosage for the one 3-year-old P was

1.  Baseline – 4months

2.  Treatment  with Music Interaction Therapy –7  months

3.  Unmonitored music therapy – 5 months

4.  Follow-up—2 years

 

•  Evidence Supporting Source #7:

–  eye contact –increased at maintenance

–  initiation-  increased after treatment and continued to increase at maintenance

–  number of interactions- increased after treatment and continued to increase at maintenance

–  naturalistic and frequent assessments

–  maintenance data

•  Evidence Contraindicating Source #7:

–  vague dosage in the critical review

–  report of single subject experimental design provided descriptive data only

–  concern about developmental effects

–  limited description of possibly confounding variables (parental involvement in treatment, P education)

–  small N

    Description of Source #8—To improve gestural, verbal, and social communication (Yeou-Cheng et al., 2006)

– Treatment involved child-centered interactive playgroups administered for 3 weeks that were integrated into the school curriculum. The music therapy playgroups incorporated verbal and visual support and experiences with songs and musical instruments.  The schedule included:

1.  Greeting song

2.  Communication based song such as fine motor skills (?) or gestural prompting

3.  Closing song

 

•  Evidence Supporting Source #8:

–  Claimed but did not provide evidence that interactive musical activities using verbal and tactile stimulation provided a better outcome

–  Unclear description of treatment procedures

•  Evidence Contraindicating Source #8:

–  Data not clearly presented

–  Small N

–  Procedures not clearly presented

     Description of  Source #9— To improve receptive imitative routines  (Stephens, 2008)

– Treatment involved

–  C played brief portions of Bob Marley songs

–  C demonstrated a word-motor action pair then played a segment of the Bob Marley song for 20 seconds in which P and C danced to the music.

–  C imitated P’s dancing and playing instruments and then modeled an action word pair for P to imitate

–  C prompted child to imitate, if necessary

– Procedures included

–  wait time

–  multiple modes of communication

–  generalization of school setting

 

•  Evidence Supporting Source #9:

–  Claimed but did not provide evidence that musical social milieu teaching improved receptive imitative routines.  The behaviors that improved were

1.  spontaneous imitation of action word pairs (3 of 4 Ps)

2.  improved motor imitation only (1 of 4 Ps)

3.  generalization imitation  (2 of 4 Ps)

4.  new turn-taking behaviors (2 of 4 Ps)

5.  more appropriate academic behaviors (2 of 4 Ps)

•  Evidence Contraindicating Source #9:

–  Intervention procedures and dosage were not clear in the review

–  Definition of terms needed (e.g., receptive imitative routines, more appropriate academic behaviors)

–  small N

–  weak experimental design

–  dosage of study based on time limitations rather than P performance


Johnson & Pring (1990)

January 5, 2014

EBP THERAPY ANALYSIS

Treatment Groups

 

NOTE:  Scroll down two-thirds of the way down to access the summary.

SOURCE:  Johnson, J. A., & Pring, T. R. (1990). Speech therapy and Parkinson’s disease: A review and further data. British Journal of Disorders of Communication, 25, 183-194.

 

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

 

DATE:  2009

ASSIGNED GRADE FOR OVERALL QUALITY:  B  (Highest possible grade was A.)

 

TAKE AWAY:  This investigation provides moderate support for the use of Robertson and Thomson’s (1986) approach for treating dysarthria associated with Parkinson’s disease in English Ps. Loudness and pitch outcomes were measured in a variety of linguistic contexts.

 

1.  What type of evidence was identified?

a.  What type of experimental design:  Prospective, Randomized Group Design with Controls

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

                                                                                                           

2.  Group membership determination:

a.  If there were groups, were participants randomly assigned to groups?  Yes. First, the 12 Ps with Parkinson’s disease were stratified and then they were randomly assigned to the treated (PD-T) and untreated (PD-U). There was also a small group of neurologically normal (NN) Ps.  Obviously, they were not randomly assigned.

 

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. Judgment of the perceptual outcome (#1, Frenchay Dysarthria Assessment) was blind.  Acoustic measures were not blinded.

                                                                    

 

4.  Were the groups adequately described?  No

 

a.         How many participants were involved in the study?

•  total # of participant:  16  

•  # of groups:  3

•  # of participants in each group: 6, 6, 4

•  List names of groups:  Parkinson’s disease treated (PD-T), Parkinson’s Disease untreated  (PD-U), neurologically normal (NN)

                                                                                

b.

— The following variables were controlled:

•  age:  PD-T = 63.5; PD-U = 64.8

•  gender:  both PD groups  5m, 1f

— The following variable was described

•  Medications:  All Ps from PD groups were stable on medications.

 

c.   Were the groups similar before intervention began?  Yes. The PD groups were similar.

                                                         

d.  Were the communication problems adequately described?  No

•  The disorder type was   dysarthria associated with PD

 

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?

a.  Was there a no intervention group?  Yes. There were 2 no treatment groups: one PD, one NN.   

                                   

b.  Was there a foil intervention group?  No

c.  Was there a comparison group?  No 

d.  Was the time involved in the foil/comparison and the target groups constant? Not Applicable 

 

7.  Were the outcomes measure appropriate and meaningful? Yes

a.  The outcomes                                                                             

OUTCOME #1:  Improved performance on the Frenchay Dysarthria Assessment

OUTCOME #2:  Increased loudest volume (dB) while counting

OUTCOME #3:  Increased volume range (dB) while counting

OUTCOME #4:  Increased volume (dB) while speaking on a selected topic (speech)

OUTCOME #5:  Increased volume (dB) while reading a selected passage (reading)

OUTCOME #6:  Improved Fo (Hz) while vocalizing “ah”

OUTCOME #7:  Increased pitch range (Hz) while singing to highest and lowest notes

OUTCOME #8:  Increased modal frequency (Hz) while speaking on a selected topic (speech)

OUTCOME #9:  Improved modal frequency (Hz) while reading a selected passage (reading)

b.  The outcome that was subjective is  

OUTCOME #1:  Improved performance on the Frenchay Dysarthria Assessment

 

c.  The outcomes that were objective are          

OUTCOME #2:  Increased loudest volume (dB) while counting

OUTCOME #3:  Increased volume range (dB) while counting

OUTCOME #4:  Increased volume (dB) while speaking on a selected topic (speech)

OUTCOME #5:  Increased volume (dB) while reading a selected passage (reading)

OUTCOME #6:  Improved Fo (Hz) while vocalizing “ah”

OUTCOME #7:  Increased pitch range (Hz) while singing to highest and lowest notes

OUTCOME #8:  Increased modal frequency (Hz) while speaking on a selected topic (speech)

OUTCOME #9:  Improved modal frequency (Hz) while reading a selected passage (reading)

 

8.  Were reliability measures provided?  No

a.  Interobserver for analyzers?  No

b.  Intraobserver for analyzers?  No

c.  Treatment fidelity for clinicians?  No 

 

9.  What were the results of the statistical (inferential) testing?  For the most part, the treatment group improved significantly on the outcomes. The untreated group usually did not evidence significant change. When significant change occurred with the untreated group, it was deterioration. The specific outcomes are listed below:

                                                                                                             

OUTCOME #1:  Improved performance on the Frenchay Dysarthria Assessment

•  pre vs post testing for treated group:  significantly higher at post  (p =0.05)

•  pre vs post testing for untreated group:  significantly lower at post (p = 0.05)

OUTCOME #2:  Increased loudest volume (dB) while counting

•  pre vs post testing for treated group:  significantly higher at post  (p =0.01)

•  pre vs post testing for untreated group:  No

OUTCOME #3:  Increased volume range (dB) while counting

•  pre vs post testing for treated group:  significantly larger at post  (p =0.0001)

•  pre vs post testing for untreated group: significantly smaller at post  (p =0.05)

•  post test scores for treated vs untreated group

OUTCOME #4:  Increased volume (dB) while speaking on a selected topic (speech)

•  pre vs post testing for treated group:  significantly higher at post  (p =0.01)

•  pre vs post testing for untreated group:  No

OUTCOME #5:  Increased volume (dB) while reading a selected passage (reading)

•  pre vs post testing for treated group: significantly higher at post  (p =0.01)

•  pre vs post testing for untreated group:  No

OUTCOME #6:  Improved Fo (Hz) while vocalizing “ah”

•  pre vs post testing for treated group:  No

•  pre vs post testing for untreated group:  No

OUTCOME #7:  Increased pitch range (Hz) while singing to highest and lowest notes

•  pre vs post testing for treated group:  significantly larger at post  (p =0.01)

•  pre vs post testing for untreated group:  No

OUTCOME #8:  Increased modal frequency (Hz) while speaking on a selected topic (speech)

•  pre vs post testing for treated group:  No

•  pre vs post testing for untreated group:  No

OUTCOME #9:  Improved modal frequency (Hz) while reading a selected passage (reading)

•  pre vs post testing for treated group: significantly lower at post  (p =0.05)

•  pre vs post testing for untreated group:  No

b.  What was the statistical test used to determine significance

•  t-test:  (These results were not reported in 9a but are not in conflict with the overall effectiveness claims. They involve comparisons of treatment group and neurologically normal controls.)

– OUTCOME #2:  Increased loudest volume (dB) while counting

– OUTCOME #3:  Increased volume range (dB) while counting

– OUTCOME #4:  Increased volume (dB) while speaking on a selected topic (speech)

– OUTCOME #5:  Increased volume (dB) while reading a selected passage (reading)

•  ANOVA:

– OUTCOME #3:  Increased volume range (dB) while counting

– OUTCOME #4:  Increased volume (dB) while speaking on a selected topic (speech)

– OUTCOME #5:  Increased volume (dB) while reading a selected passage (reading)

– OUTCOME #6:  Improved Fo (Hz) while vocalizing “ah”

– OUTCOME #7:  Increased pitch range (Hz) while singing to highest and lowest notes

– OUTCOME #8:  Increased modal frequency (Hz) while speaking on a selected topic (speech)

– OUTCOME #9:  Improved modal frequency (Hz) while reading a selected passage (reading)

 

•  Wilcoxan:

– OUTCOME #1:  Improved performance on the Frenchay Dysarthria Assessment

 

c.  Were confidence interval (CI) provided?  No

                                   

10.  What is the clinical significance?  Not provided

 

11.  Were maintenance data reported?  No

 

12.  Were generalization data reported?  Yes. Some of the outcomes involved spontaneous speech and, therefore, may be considered generalizations.  The treated group improved on measures of spontaneous speech of loudness but not pitch.

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  B

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate effectiveness of an intervention based on Robertson and Thomson (1986) with a relatively brief amount of treatment.

POPULATION:  dysarthria associated with Parkinson’s disease

 

MODALITY TARGETED:  expression

 

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

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  overall performance on Frenchay Dysarthria Assessment

DOSAGE:  ten 45-minute sessions within a 4 week period

 

ADMINISTRATOR:  SLP

 

STIMULI:  auditory, visual (Visipitch, sound level meter, Jedcom vocal loudness indicator)

 

MAJOR COMPONENTS:

 

•  Based on:  Robertson, S. J., & Thomson, F. (1986). Working with dysarthrics.  Bucks, UK: Winslow Press.

 

•  Focus of treatment: pitch and loudness

•  Feedback:  Visipitch, sound level meter, Jedcom vocal loudness indicator)

•  Interventions modified to fit needs of the individual Ps.

•  Investigators provided plans for the 10 sessions:

#1, #2:  relaxed breathing, coordination of breathing and phonation

#3: loudness and loudness contrasts

#4: stress (lexical, contrastive/emphatic)

#5: imitation and normalization of pitch patterns and pitch range

#6: intonation (terminal contour) exercises

#7: continue #6 and extend to practicing appropriate intonation patterns in questions and answers

#8: improve articulation clarity

#9:  practice on loudness;  then read passages with good loudness and articulation

#10: work on rate of speech as well as using appropriate breath control, loudness, and pitch