Ramig et al. (2001)

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

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