Ramig et al. (1995)

EBP THERAPY ANALYSIS

Treatment Groups

 

SOURCE:  Ramig, L. O., Countryman, S., Thompson, L. L., & Horii, Y. (1995). Comparision of two forms of intensive speech treatment for Parkinson disease. Journal of Speech and Hearing Research, 38, 1232-1251.

 

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

 

DATE:  2009

ASSIGNED GRADE FOR OVERALL QUALITY:  A-  (The highest grade this paper could receive was A.) 

 

TAKE AWAY:  This investigation is part of the body of literature providing strong support for Lee Silverman Voice Treatment (LSVT) to improve loudness of speakers with Parkinson’s disease. In this investigation, the investigators compared LSVT to respiration-based (R) therapy.  Both approaches yielded significant changes in loudness as well as other outcomes (i.e., rate (utterance duration), pause duration, duration, pitch variability, fo, initiation of conversation, monotonicity, hoarseness, intelligibility.

 

 

1.  What type of evidence was identified?

a.  What was the type of evidence? 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. All Ps were stratified and then randomly assigned to Lee Silverman Voice Treatment (LSVT) or respiration treatment (R) groups.

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 participant:  45  

•  # of groups:  2

•  # of participants in each group:  26 (LSVT) and 19 (R)

•  List names of groups:    Lee Silverman Voice Treatment (LSVT) and  Respiration treatment (R)

 

b.  The following variables were controlled as Ps were stratified before random assignment:            

•  age:  LSVT –females  56,  males 65.3; R —  females 66.9, males 64.9

•  gender:  LSVT –females  5,  males 21; R —  females 7, males 12

•  motor skills:  LSVT –females 20.25,  males 28 ; R —  females 23.6, males 27.1 (NOTE:  higher the score = higher disability, range on test 0-108.)

•  time since diagnosis:  LSVT –females 6.8 years,  males 8.7 years; R —  females  3.4 years, males 7.3 years

•  severity of speech disorder:  LSVT –females 2.4,  males 2.86; R —  females 2.29, males 3.0  (NOTE:  1-5 scale , 1 = mild, 5 = severe)

•  stage of disease:  LSVT –females 2.5,  males 2.7; R —  females 3.0, males 2.4 

•  glottal incompetence:  LSVT –females 1.75,  males 1.5; R —  females 1.8, males  1.1 (NOTE:  due to invasiveness of procedure, only 20 Ps participated; 1-5 scale, 1= slight, 5 = severe)

•  medications:  all were stable during investigation

•  other interventions:  none during investigation

 

The following variables were described:

•  cognitive functioning:  LSVT –females 41.79,  males  44.59; R —  females   46.47, males  44.24 (NOTE: scores below 40 are indicative of impairment)

•   depression:  LSVT –females 15,  males 7.57; R —  females 11.71, males  8.83  (NOTE:  note of 9 on higher on this self rating scale is indicative of some depression)

•  impact of sickness-communication:  LSVT –females 28.19,  males 35.11; R —   females 26.54, males  30.68  (NOTE:  0.00 = no problems due to sickness in this domain)

•  impact of sickness-social interaction:  LSVT –females 16.74,  males 7.40; R —  females 14.80, males 12.27 (NOTE:  0.00 = no problems due to sickness in this domain)

 

c.   Were the groups similar before intervention began?  Yes

                                                         

d.  Were the communication problems adequately described?  Yes

•  disorder type:  dysarthria associated with Parkinson Disease

•  speech characteristics:  a variety of deficits including

–  reduced loudness

–  imprecise articulation

–  rapid rate

–  hoarseness

–  tremor

–  monotone

–  aphonia

–  strained/strangled

–  slow rate

–  pallilalia

 

5.  Was membership in groups maintained throughout the study?

a.  Did each of the groups maintain at least 80% of their original members?  Unclear. Forty-five Ps were involved in the study and data were provided for those 45. However, the investigators note that some Ps (number was not provided) did not complete the study due to noncompliance with assessments or treatment procedures.

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

 

6.   Were the groups controlled acceptably?

a.  Was there a no intervention group?  No  

b.  Was there a foil intervention group?  No

c.  Was there a comparison group?  Yes

d.  Was the time involved in the foil/comparison and the target groups constant?  Yes

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

OUTCOME #1:  Improved sound pressure level (SPL) for phonation

OUTCOME #2:  Improved sound pressure level (SPL) for reading

OUTCOME #3:  Improved sound pressure level (SPL) for monologue

OUTCOME #4:  Improved duration for sustained phonation

OUTCOME #5:  Improved pitch variability in semitones for reading

OUTCOME #6:  Improved pitch variability in semitones for monologues

OUTCOME #7:  Improved fo for reading

OUTCOME #8:  Improved fo for monologues

OUTCOME #9:  Improved utterance duration (rate) for reading

OUTCOME #10:  Improved utterance duration (rate) for monologues

OUTCOME #11:  Improved pause duration for reading

OUTCOME #12:  Improved pause duration for monologue

OUTCOME #13:  Improved Forced Vital Capacity (FVC)

OUTCOME #14:  Improved self-ratings of loudness

OUTCOME #15:  Improved self-ratings of monotonicity

OUTCOME #16:  Improved self-ratings of hoarseness

OUTCOME #17:  Improved self-ratings of intelligibility

OUTCOME #18:  Improved self-ratings of ability to initiate conversation

OUTCOME #19:  Improved family-ratings of loudness

OUTCOME #20:  Improved family- ratings of monotonicity

OUTCOME #21:  Improved family-ratings of hoarseness

OUTCOME #22:  Improved family-ratings of intelligibility

OUTCOME #23:  Improved family-ratings of ability to initiate conversation

b.  The subjective  outcome measures

OUTCOME #14:  Improved self-ratings of loudness

OUTCOME #15:  Improved self-ratings of monotonicity

OUTCOME #16:  Improved self-ratings of hoarseness

OUTCOME #17:  Improved self-ratings of intelligibility

OUTCOME #18:  Improved self-ratings of ability to initiate conversation

OUTCOME #19:  Improved family-ratings of loudness

OUTCOME #20:  Improved family- ratings of monotonicity

OUTCOME #21:  Improved family-ratings of hoarseness

OUTCOME #22:  Improved family-ratings of intelligibility

OUTCOME #23:  Improved family-ratings of ability to initiate conversation

 

c.  The objective  outcome measures were

OUTCOME #1:  Improved sound pressure level (SPL) for phonation

OUTCOME #2:  Improved sound pressure level (SPL) for reading

OUTCOME #3:  Improved sound pressure level (SPL) for monologue

OUTCOME #4:  Improved duration for sustained phonation

OUTCOME #5:  Improved pitch variability in semitones for reading

OUTCOME #6:  Improved pitch variability in semitones for monologues

OUTCOME #7:  Improved fo for reading

OUTCOME #8:  Improved fo for monologues

OUTCOME #9:  Improved utterance duration (rate) for reading

OUTCOME #10:  Improved utterance duration (rate) for monologues

OUTCOME #11:  Improved pause duration for reading

OUTCOME #12:  Improved pause duration for monologue

OUTCOME #13:  Improved Forced Vital Capacity (FVC)

 

8.  Were reliability measures provided?

                                                                                                             

a.  Interobserver for analyzers?

b.  Intraobserver for analyzers?  No. But the investigators provided intrasubject reliability data. They correlated (1) the first pretest with the second pretest and (2) the first post test with the second post test. The results are listed below:

 

OUTCOME #1:  Improved sound pressure level (SPL) for phonation

(1) the first pretest with the second pretest:  r = 0.78

(2) the first post test with the second post test:  r = 0.96

OUTCOME #2:  Improved sound pressure level (SPL) for reading

(1) the first pretest with the second pretest:  r = 0. 78

(2) the first post test with the second post test:  r = 0.97

 

OUTCOME #3:  Improved sound pressure level (SPL) for monologue

(1) the first pretest with the second pretest:  r = 0.82

(2) the first post test with the second post test:  r = 0.82

 

OUTCOME #4:  Improved duration for sustained phonation

(1) the first pretest with the second pretest:  r = 0. 83

(2) the first post test with the second post test:  r = 0.93

 

OUTCOME #5:  Improved pitch variability in semitones for reading

(1) the first pretest with the second pretest:  r = 0. 95

(2) the first post test with the second post test:  r = 0.91

OUTCOME #6:  Improved pitch variability in semitones for monologues

(1) the first pretest with the second pretest:  r = 0.39

(2) the first post test with the second post test:  r = 0.43

 

OUTCOME #7:  Improved fo for reading

(1) the first pretest with the second pretest:  r = 0.98

(2) the first post test with the second post test:  r = 0.99

 

OUTCOME #8:  Improved fo for monologues

(1) the first pretest with the second pretest:  r = 0. 96

(2)  the first post test with the second post test:  r = 0.96

 

OUTCOME #13:  Improved Forced Vital Capacity (FVC)

(1) the first pretest with the second pretest:  r = 0.98

(2) the first post test with the second post test:  r = 0.99

 

OUTCOME #14:  Improved self-ratings of loudness

(1) the first pretest with the second pretest:  r = 0.65

(2)  the first post test with the second post test:  r = 0.68

OUTCOME #15:  Improved self-ratings of monotonicity

(1) the first pretest with the second pretest:  r = 0.55

(2) the first post test with the second post test:  r = 0.72

OUTCOME #16:  Improved self-ratings of hoarseness

(1) the first pretest with the second pretest:  r = 0.69

(2) the first post test with the second post test:  r = 0.45

 

OUTCOME #17:  Improved self-ratings of intelligibility

(1) the first pretest with the second pretest:  r = 0.67

(2) the first post test with the second post test:  r = 0.76

 

OUTCOME #18:  Improved self-ratings of ability to initiate conversation

(1) the first pretest with the second pretest:  r = 0.81

(2) the first post test with the second post test:  r = 0.83

OUTCOME #19:  Improved family-ratings of loudness

(1) the first pretest with the second pretest:  r = 0.61

(2) the first post test with the second post test:  r = 0.86

OUTCOME #20:  Improved family- ratings of monotonicity

(1) the first pretest with the second pretest:  r = 0. 87

(2) the first post test with the second post test:  r = 0.99

OUTCOME #21:  Improved family-ratings of hoarseness

(1) the first pretest with the second pretest:  r = 0. 75

(2) the first post test with the second post test:  r = 0.92

 

OUTCOME #22:  Improved family-ratings of intelligibility

(1) the first pretest with the second pretest:  r = 0.63

(2) the first post test with the second post test:  r = 0.98

 

OUTCOME #23:  Improved family-ratings of ability to initiate conversation

(1) the first pretest with the second pretest:  r = 0.93

(2)  the first post test with the second post test:  r = 0.71

 

c.  Treatment fidelity for clinicians?  No , but the investigators notes that the Cs worked to insure consistency of treatment.

 

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

                                                                                                             

TREATMENT Versus COMPARISON GROUP COMPARISON:  Overall, the outcomes were similar for the 2 treatments with the following exception:

•  LSVT had significant improvement but the R did not for

  – Outcomes 1, 6, 22

• R had significant improvement but the LSVT did not for

  – Outcomes 11

•  Specific comparisons for treatment groups are

OUTCOME #1:  Improved sound pressure level (SPL) for phonation

Treatment groups that improved significantly from pre to post test:  LSVT (male and female Ps)

OUTCOME #2:  Improved sound pressure level (SPL) for reading

Treatment groups that improved significantly from pre to post test:  LSVT (male and female Ps); R (female Ps)

 

OUTCOME #3:  Improved sound pressure level (SPL) for monologue

     Treatment groups that improved significantly: LSVT and R, both genders

 

OUTCOME #4:  Improved duration for sustained phonation:

Treatment groups that improved significantly from pre to post test: LSVT and R, both genders

OUTCOME #5:  Improved pitch variability in semitones for reading:

Treatment groups that improved significantly from pre to post test:  LSVT and R, both genders

OUTCOME #6:  Improved pitch variability in semitones for monologues:

Treatment groups that improved significantly from pre to post test:  LSVT, both genders

 

OUTCOME #7:  Improved fo for reading:

Treatment groups that improved significantly from pre to post test:  LSVT and R, both genders

 

OUTCOME #8:  Improved fo for monologues:

Treatment groups that improved significantly from pre to post test:  none

 

OUTCOME #9:  Improved utterance duration (rate) for reading:

Treatment groups that improved (reduced) significantly from pre to post test:  LSVT and R, both genders

 

OUTCOME #10:  Improved utterance duration (rate) for monologues:

Treatment groups that improved significantly from pre to post test:  None

 

OUTCOME #11:  Improved pause duration for reading:

Treatment groups that improved (increased) significantly from pre to post test:  R, both genders

 

OUTCOME #12:  Improved pause duration for monologue:

Treatment groups that improved significantly from pre to post test:  None

 

OUTCOME #13:  Improved Forced Vital Capacity (FVC):

Treatment groups that improved significantly from pre to post test:  None

OUTCOME #14:  Improved self-ratings of loudness:

Treatment groups that improved significantly from pre to post test:  LVST males; R females

OUTCOME #15:  Improved self-ratings of monotonicity:

Treatment groups that improved significantly from pre to post test:  LSVT and R, both genders

OUTCOME #16:  Improved self-ratings of hoarseness:

Treatment groups that improved significantly from pre to post test:  LSVT and R, both genders

 

OUTCOME #17:  Improved self-ratings of intelligibility:

Treatment groups that improved significantly from pre to post test:  LSVT and R, both genders

 

OUTCOME #18:  Improved self-ratings of ability to initiate conversation;

Treatment groups that improved significantly from pre to post test:  LSVT and R, both genders

OUTCOME #19:  Improved family-ratings of loudness:

Treatment groups that improved significantly from pre to post test:  LSVT and R, both genders

OUTCOME #20:  Improved family- ratings of monotonicity:

Treatment groups that improved significantly from pre to post test:  None

OUTCOME #21:  Improved family-ratings of hoarseness:

Treatment groups that improved significantly from pre to post test:  None

 

OUTCOME #22:  Improved family-ratings of intelligibility:

Treatment groups that improved significantly from pre to post test:  LSVT, both genders

 

OUTCOME #23:  Improved family-ratings of ability to initiate conversation:  None

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

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?  No, but the targets in therapy ranged from sustained vowels to conversation.

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: A-

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To compare the effectiveness of Lee Silverman Voice Treatment  (LSVT, vocal fold adduction and respiratory support) and Respiration (R, respiratory support) therapy for speakers with Parkinson’s disease

POPULATION:  Parkinson’s disease (adult)

 

MODALITY TARGETED:  production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness*, duration*, rate* (utterance duration), pause duration**, pitch variability*, Fo*

 * = at least one outcome was associated with significant improvement for this target for LVST and R treatments; for outcomes (1, 6) only LVST yielded significant improvement.

** = one outcome associated with pause duration yielded significant improvement for R.

ELEMENTS OF PROSODY USED AS INTERVENTION:  loudness (LSVT), duration (R)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED (Dependent variable):  forced vital capacity, hoarseness*, intelligibility*, initiation of conversation*

* = at least one outcome was associated with significant improvement for this target for both LSVT and R.

DOSAGE:  50 minute sessions, 4 times a week for 4 weeks (16 sessions)

 

ADMINISTRATOR: SLP

 

STIMULI: auditory, visual (including stop watch, voice light, respigraph, visipitch) depending on treatment group (R or LSVT)

 

MAJOR COMPONENTS:

 

•  Timed agenda for sessions:

– 25 minutes: maximum effort drills

– 25 high effort speech production tasks with the following hierarchy

1.  single words

2.  phrases

3.  sentences

4.  reading

5.  conversation

– homework was regularly assigned

RESPIRATION  (R) TREATMENT:

•  High effort exercise to increase

–  muscle activity associated with respiration and

–  sustained vocalizations

•  Sample tasks:

–  maximum inhalation tasks

–  maximum exhalation tasks

–  maximum duration of /s/ and /f/

–  sustaining intraoral air pressure

•  Cs taught Ps to breath deeply and frequently during reading and conversing

•  Feedback was visual (Respigraph)

•  Cs did not teach P about

–  vocal fold adduction

–  increasing loudness

LEE SILVERMAN VOICE TREATMENT (LSVT):

•  Focus:  high effort using healthy phonation strategies, increase loudness by increasing adduction of vocal folds,

•  Task to elicit increased vocal fold adduction:

– pushing hands together while phonating

– pushing down with hands while phonating

– pushing on chair while phonating

–  lifting up a chair while phonating

•  Drill included

– maximum duration of /a/

– maximum Fo range

•  C prompts, cues, hints

– think aloud

– use same loudness in conversation and reading as in maximum duration tasks

–  “take deep breaths” and “speak ‘on top of the breath’”

•  Loudness Feedback

– voice light

– tape recorder

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