Pennington et al. (2009)

April 30, 2014

SECONDARY REVIEW CRITIQUE

 

Note: Brief summaries of the interventions concerned with treating prosody or using prosody to treat other outcomes can be accessed by scrolling about two-thirds of the way down.

 

 

Source: Pennington L, Miller N, & Robson S. (2009). Speech therapy for children with dysarthria acquired before three years of age. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006937. DOI: 10.1002/14651858.CD006937.pub2

Reviewer(s): pmh

 

Date: April 30, 2014

 

Overall Assigned Grade: A (Highest possible grade based on the design is A+.)

 

Level of Evidence: A+

 

Take Away: Because the search revealed no experimental or quasi-experimental studies, some of the components of a Systematic Review were not completed. The authors did review 10 observational sources that provided some level of evidence but only six were clearly concerned with prosody. The SR noted that treating certain aspects of prosody may result in improved intelligibility, certain aspects of voice quality, and articulation. Only the prosody related critiques were reviewed below.

 

What type of secondary review? Classic Systematic Review

 

1. Were the results valid? Yes

a. Was the review based on a clinically sound clinical question? Yes

b. Did the reviewers 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:

• conference proceedings

• hand searches

• internet based databases    

d. Did the potential sources involve only English language publications? No, sources could be in any language

e. Did the potential sources include unpublished studies? Yes

f. Was the time frame for the publication of the sources sufficient? Yes

g. Did the reviewers identify the level of evidence of the sources?

Yes, the reviewers noted that all reviewed sources did not meet inclusion criteria as they were observational investigations

h. Did the reviewers describe procedures used to evaluate the validity of each of the sources? Yes

i. Was there evidence that a specific, predetermined strategy was used to evaluate the sources? Yes

j. Did the reviewers or review teams rate the sources independently? Yes

k. Were interrater reliability data provided? Yes

l. What was the interrater reliability for exclusion of the 10 sources? 100%

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? Yes, but these were for sources that were excluded from the Systematic Review.

q. Were there a sufficient number of sources? No

2. Description of outcome measures:

• Outcome Fox (2005): To improve

– sound pressure level (SPL),

– maximum duration,

– maximum and minimum pitch in HZ,

– pitch range in HZ,

– harmonics to noise ratio (HNR)

– C’s preference for loudness

– C’s preference for loudness variability

– C’s preference of overall pitch

– C’s preference for pitch variability

– C’s preference for articulatory precision

– C’s preference for overall voice quality

• Outcome Fox (2008): To improve

– sound pressure level (SPL),

– harmonics to noise ratio (HNR)

– jitter

– duration in maximum duration and sentence repetition tasks

– Parents’ preference for voice quality

• Outcomes for Pennington (2006): To improve

– intelligibility

– P’s perception of acceptability of the intervention

• Outcome for Pennington (2009): To improve

– intelligibility

– P’s perception of acceptability of the intervention

• Outcome for Puyuelo (2005): To improve measures of

– voice control

– intelligibility

– respiration

– articulation

– prosody

• Outcome for Robson (2009): To improve

– perception of severity of voice impairment

– harmonics to noise ratio

– jitter

– shimmer

– mean fundamental frequency

– rate with pauses

– rate without pauses

– time with pauses

– time without pauses

 

 

3. Description of results:

a. What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? No EBP metrics were provided

b. Summarize overall findings of the secondary review:

• The reviewers found no research meeting the criteria which included experimental and quasi-experimental designs (i.e. controlled studies).

• The review of the observational studies revealed that focusing on certain aspects of prosody may result in improved intelligibility, certain aspects of voice quality, and articulation. However, these results need to be verified using more rigorous research designs.

c. Were the results precise? Unclear

d. If confidence intervals were provided in the sources, did the reviewers consider whether evaluations would have varied if the “true” value of metrics were at the upper or lower boundary of the confidence interval? Not Applicable

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

f. For the most part, were the results similar from source to source? Yes

g. Were the results in the same direction? Yes

h. Did a forest plot indicate homogeneity? Not

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?Yes. The reviewers noted whether or not maintenance data were collected, although the outcomes were not always reported in the Systematic Review. When maintenance results were reported, the findings were inconsistent.

 

 

SUMMARY OF INTERVENTION

 

Population:Cerebral Palsy, Dysarthria; Child

 

Prosodic Targets:

– sound pressure level (SPL),

– maximum duration,

– maximum and minimum pitch in HZ,

– pitch range in HZ,

– C’s preference for loudness

– C’s preference for loudness variability

– C’s preference of overall pitch

– C’s preference for pitch variability

– duration in maximum duration and sentence repetition tasks

– prosody

– mean fundamental frequency

– rate with pauses

– rate without pauses

– time with pauses

– time without pauses

 

Nonprosodic Targets:

– harmonics to noise ratio (HNR)

– C’s preference for articulatory precision

– C’s preference for overall voice quality

– jitter

– Parents’ preference for voice quality

– intelligibility

– P’s perception of acceptability of the intervention

– voice control

– respiration

– articulation

– perception of severity of voice impairment

– harmonics to noise ratio

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: rate, loudness, prosodic contrasts (not defined), intonation, pausing, rhythm, duration

 

 

Description of Procedure associated with Fox (2005):

• Outcome: To improve

Acoustic Measures

– sound pressure level (SPL),

– maximum duration,

– maximum and minimum pitch in HZ,

– pitch range in HZ,

– harmonics to noise ratio (HNR)

Perceptual Measures

– C’s preference for loudness

– C’s preference for loudness variability

– C’s preference of overall pitch

– C’s preference for pitch variability

– C’s preference for articulatory precision

– C’s preference for overall voice quality

• The intervention involved administration of Lee Silverman Voice Therapy Loud.

 

Evidence Supporting Procedure associated with Fox (2005)

– Improvement in all acoustic outcomes for 3 of the 4 Ps who received treatment. This improvement was maintained at follow-up.

– With the exception of overall pitch, therapists preferred the post treatment perceptual measures.

 

 

Description of Procedure associated with Fox (2008):

• OUTCOME: To improve

– sound pressure level (SPL),

– harmonics to noise ratio (HNR)

– jitter

– duration in maximum duration and sentence repetition tasks

– Parents’ preference for voice quality

• The intervention involved administration of Lee Silverman Voice Therapy Loud.

 

Evidence Supporting Procedure associated with Fox (2008)

– Improvement in SPL in sustained vowels (post therapy and follow-up) and in sentences (after therapy)

– Improvements in jitter (post therapy and follow-up)

– After therapy, parents rated their children’s voices as “louder”, less “nasal” and more “natural”.

 

Evidence Contraindicating Procedure associated with Fox (2008)

– Analyzers were not blinded.

 

 

Description of Procedure associated with Pennington (2006):

• OUTCOME: To improve

– intelligibility

– P’s perception of acceptability of the intervention

• The investigators employed asystems approach to intervention focusing on breath control for speech and prosodic contrasts. These terms were not described in the Systematic Review.

 

Evidence Supporting Procedure associated with Pennington (2006)

• 4 of the 6 Ps improved single intelligibility post therapy but not at follow-up.

• 3 of 6 Ps improved connected speech intelligibility post therapy but not at follow-up.

• 3 of the 6 Ps perceived duration and intensity of the intervention to be acceptable

Evidence Contraindicating Procedure associated with Pennington (2006)

• No control group.

 

 

Description of Procedure associated with Pennington (2009):

• OUTCOME: To improve

– intelligibility

– P’s perception of acceptability of the intervention

• The investigators used a systems approaching targeting the stabilization of respiration, phonatory effort, speech rate, and phrase length or syllables per breath.

 

Evidence Supporting Procedure associated with Pennington (2009)

• 15 of the 16 Ps improved intelligibility.

• All P reported satisfaction with the intervention procedures.

 

Evidence Contraindicating Procedure associated with Pennington (2009)

•  No treatment fidelity treatment.

• No maintenance data.

 

 

Description of Procedure associated with Puyuelo (2005):

• OUTCOME: To improve measures of

– voice control

– intelligibility

– respiration

– articulation

– prosody

• There were 2 blocks of therapy:

Block1. Improving motor control by focusing on articulation, chewing, and expiratory breathing. (This was not successful.)

Block2. Improving control of exhalation for speech, coordinating exhalation and phonation, voice training, and prosody (intonation, pause, rhythm, and duration). Parents were also involved in this block (speech stimulation activities and use of narratives).

 

Evidence Supporting Procedure associated with Puyuelo (2005)

• Block 1 yielded improvement only in voice control.

• In Block 2 resulted in improvement of

– respiration

– voice

– articulation

– intelligibility

– prosody

 

Evidence Contraindicating Procedure associated with Puyuelo (2005)

• Long duration of intervention.

• Block 1 yielded improvement only in voice control.

• No control group.

• Data analyzers were not blinded.

 

 

Description of Procedure associated with Robson (2009):

• OUTCOME: To improve

– perception of severity of voice impairment

– harmonics to noise ratio

– jitter

– shimmer

– mean fundamental frequency

– rate with pauses

– rate without pauses

– time with pauses

– time without pauses

• The investigators used a systems approaching targeting the stabilization of respiration, phonatory effort, speech rate, and phrase length or syllables per breath.

 

Evidence Supporting Procedure associated with Robson (2009)

• The investigators reported

– Limited decrease in fundamental frequency,

– Limited decrease in intensity

– Limited decrease in jitter of children’s voices.

– Limited increase in speaking time between pauses.

 

Evidence Contraindicating Procedure associated with Robson (2009)

• The investigators did not find a change in perceived severity of voice impairment.

• No maintenance data.

 

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Solomom et al. (2001)

April 23, 2014

EBP THERAPY ANALYSIS for

Single Subject Designs

 

Note: The summary can be viewed by scrolling about two-thirds of the way down on this page.

 

SOURCE: Solomon, N. P., McKee, A. S., & Garcia-Barry, S. (2001). Intensive voice treatment and respiration treatment for hypokinetic-spastic dysarthria after traumatic brain injury. American Journal of Speech-Language Pathology, 10, 51-64.

 

REVIEWER(S): pmh

 

DATE: April 22, 2014

 

ASSIGNED OVERALL GRADE: D+(This was a case study; therefore, the highest possible grade was D+.)

 

TAKE AWAY: This thorough case study provides guidance about use of Lee Silverman Voice Treatment (LSVT) and Combination therapy (LSVT plus Respiration therapy and Physical therapy) with a P with hypokinetic and spastic dysarthria as the result of traumatic brain injury (TBI). Some measures of breathing, intelligibility, and sound pressure level (SPL) improved.

                                                                                                           

 

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? Case Studies- Description with Pre and Post Test Results    

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

                                                                                                           

3. Was phase of treatment concealed?

a. from participants? No

b. from clinicians? No

c. from data analyzers? Yes, perceptual measures were randomly presented to data analyzers (judges).

 

4. Was the participant adequately described? Yes, the description of the P was very thorough.

a. How many participants were involved in the study? List here: 1

 

b. The following characteristics/variables were described:

• age: ~ 25 years

• gender: m

• cognitive skills: intact attention and executive skills; 6th to 13th percentile on subtests of the Woodcock & Johnson Tests of Cognitive Ability-Revised; memory was moderately impaired

• receptive language: auditory and reading comprehension impairments

• etiology: Traumatic Brain Injury                         

• damage: “diffuse edema, small amounts of subarachnoid blood around the interpeduncular cistern, and punctate hemorrhages throughout the cortical white matter” (p. 52)

• coma: yes, started to regain consciousness at 1 month post-accident,

• previous therapy: received treatment until investigation began

 

c. Were the communication problems adequately described? Yes

• List the disorder type(s): hypokinetic-spastic dysarthria

• Other aspects of communication that were described included

Intelligibility: 40% in conversations with unfamiliar listeners; 50% in group therapy

hearing: within normal limits

oral motor skills:

• facial drooped on right side when at rest

• reduced range of motion for lips on right side

• reduced lip resistance

• reduced bilateral range of motion for tongue

– speech skills:

• diadochokinetic rate: rapid, blurred

• voice quality: breathy, rough, decreased loudness, monopitch, monoloudness

• imprecise consonant production

• resonance: slightly hypernasal

• prosody: slow, short rushes of rapid speech, long pauses

– pulmonary function:

• obstruction ruled out but forced vital capacity (FVC) was 54% of expectation

• slow vital capacity: 70% of expected value; problems with inspiration and expiration.

• chest wall kinematics: atypical at rest, reading, and in monologues.

                                                                                                                       

 

5. Was membership in treatment maintained throughout the study? Not applicable           

a. If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable

b. Were any data removed from the study? No

 

6. Did the design include appropriate controls? No, this was a case study.

a. Were preintervention data collected on all behaviors? Yes

b. Did intervention data include untrained data? Yes

c. Did intervention data include trained data? No

d. Was the data collection continuous? Yes

e. Were different treatment counterbalanced or randomized? No

 

7. Were the outcomes measure appropriate and meaningful? Yes

a. The outcomes were

OUTCOME #1: to improve vital capacity

OUTCOME #2: to improve chest wall kinematics

PERCEPTUAL MEASURES

OUTCOME #3: to improve intelligibility in words and in sentences

OUTCOME #4: to Improve ratings of vocal roughness in reading and in monologues

OUTCOME #5: to improve ratings of vocal press (breathy to strained) in reading and in monologues

OUTCOME #6: to improve ratings of intonation (monotone to excessive variation) in reading and in monologues

OUTCOME #7: to improve ratings of loudness in reading and in monologues

ACOUSTIC MEASURES

OUTCOME #8: to improve sound pressure level (SPL) in reading and in monologues

OUTCOME #9: to improve speaking fundamental frequency (SF0) in reading and in monologues

OUTCOME #10: to improve the number of syllables produced per breath in reading and in monologues

OUTCOME #11: to improve interpause speech rate in reading and in monologues

 

b. The outcomes that are subjective are

• OUTCOME #3 (to improve intelligibility in words and in sentences)

• OUTCOME #4 (to Improve ratings of vocal roughness in reading and in monologues)

• OUTCOME #5 [to improve ratings of vocal press (breathy to strained) in reading and in monologues]

• OUTCOME #6 [to improve ratings of intonation (monotone to excessive variation) in reading and in monologue]

  • OUTCOME #7 (to improve loudness in reading and in monologues)

                                                       

c. List numbers of the outcomes that are objective:

• OUTCOME #1 (to improve vital capacity)

• OUTCOME #2 (to improve chest wall kinematics)

• OUTCOME #8 [to improve sound pressure level (SPL) in reading and in monologues]

• OUTCOME #9 [to improve speaking fundamental frequency (SF0) in reading and in monologues]

  • OUTCOME #10 (to improve the number of syllables produced per breath in reading and in monologues)

• OUTCOME #11 (to improve interpause speech rate in reading and in monologues)

 

d. The outcome measures that have supporting reliability data are

• OUTCOME #3 (to improve intelligibility in words and in sentences)

• OUTCOME #4 (to improve ratings of vocal roughness in reading and in monologues)

• OUTCOME #5 [to improve ratings of vocal press (breathy to strained) in reading and in monologues]

• OUTCOME #6 [to improve ratings of intonation (monotone to excessive variation) in reading and in monologue]

  • OUTCOME #7 (to improve loudness in reading and in monologues)

                       

e. Tthe data supporting reliability is

• The overall intraclass correlation coefficient for Outcomes 3 through 7 was 0.837.

 

 

8. Results:

a. Did the target behavior improve when it was treated? Yes, but it was Inconsistent as most but not all of the outcomes improved following either LSVT and/or Combination therapy.

b.   The overall quality of improvement for the different outcomes was

OUTCOME #1: to improve vital capacity: moderate improvement

OUTCOME #2: to improve chest wall kinematics: limited improvement

PERCEPTUAL MEASURES

OUTCOME #3: to improve intelligibility in words and in sentences: ineffective for LSVT and limited for Combination treatment

OUTCOME #4: to Improve ratings of vocal roughness in reading and in monologues: ineffective

OUTCOME #5: to improve ratings of vocal press (breathy to strained) in reading and in monologues: limited improvement for LVST and ineffective for Combination

OUTCOME #6: to improve ratings of intonation (monotone to excessive variation) in reading and in monologues: ineffective

OUTCOME #7: to improve ratings of loudness in reading and in monologues: limited improvement for LSVT but contraindicated for Combination Treatment

ACOUSTIC MEASURES:

OUTCOME #8: to improve sound pressure level (SPL) in reading and in monologues: moderate improvement (

OUTCOME #9: to improve speaking fundamental frequency (SF0) in reading and in monologues: ineffective

OUTCOME #10: to improve the number of syllables produced per breath in reading and in monologues: ineffective

OUTCOME #11: to improve interpause speech rate in reading and in monologues: limited

 

9. Description of baseline:

a. Were baseline data provided? Yes. Each outcome has one baseline data point.

b. Was baseline low (or high, as appropriate) and stable? (The numbers should match the numbers in item 7a.) NA

c. What was the percentage of nonoverlapping data (PND)? NA

 

 

10. What was the magnitude of the treatment effect? NA

 

 

11. Was information about treatment fidelity adequate? Not Provided

 

 

12. Were maintenance data reported?Yes. Maintenance data were elicited for Outcomes 3-11 about 3 months after the termination of therapy. In some cases, gains were maintained (e.g., SPL, intelligibility, some resting breathing measures, some speech breathing), in others it was reversed.

 

 

13. Were generalization data reported?Yes. The investigators added an additional 10 week course of Combination treatment to facilitate generalization. Gains were generally maintained. (See the Major Components section of the Summary for a description of the procedures.)

 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D+

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: to investigate the effectiveness of LSVT and Combination treatment on speech and breathing outcomes for a P with hypokinetic-spastic dysarthria that was the result of traumatic brain injury.

 

POPULATION: Traumatic Brain Injury; Hypokinetic-Spastic Dysarthria; Adult

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, intonation (range), pausing, rate

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness

 

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: breathing, voice quality, intelligibility

 

DOSAGE: 3 phases: (1) LSVT Phase, 1 hour sessions, 4 days a week, 4 weeks; (2) Combination Treatment Phase, 1 hour sessions, 4 days a week, 6 weeks; (3) Facilitate Carry Over Phase—1 hour of Combination Treatment per week for 10 weeks

 

ADMINISTRATOR: SLP; during Combination Therapy, P also received treatment from a Physical Therapist (PT)

 

MAJOR COMPONENTS:

 

– 3 phases:

 

1. LSVT PHASE

• C administered LSVT using the standard procedures

 

2. COMBINATION TREATMENT PHASE

• 1 day a week, P received only LSVT and 3 days a week he received a combination of LSVT and respiration treatment. C administered respiration treatment administered during the first ½ of the session and included respiration improvement techniques and cues during LSVT.

• C administered LSVT using standard procedures

• P (and the PT during PT sessions) administered treatments to improve the function of the upper chest wall. Respiration treatment included

– torso-extension stretches (SLP and PT)

– towel and corner stretches (PT)

– maximal inhalation and exhalation against resistance (SLP)

– expiration exercises with visual feedback (SLP)

– homework

 

3. FACILITATE CARRY OVER PHASE

• C administered Combination Treatment procedures 1 time a week.

• P completed homework activities 3 times a week

• C also administered ½ hour of therapy focusing on the use of a planner and completing tasks each week.

• P did not receive PT during this phase.

 


Holck (2004)

April 16, 2014

EBP THERAPY ANALYSIS for

Single Subject Designs

 

Note: The summary can be viewed by scrolling about two-thirds of the way down on this page.

 

SOURCE: Holck, U. (2004). Turn-taking in music therapy with children with communication disorders. British Journal of Music Therapy, 2, 45-53.

 

REVIEWER(S): pmh

 

DATE: April 12, 2014

 

ASSIGNED OVERALL GRADE: D- (Due to the case study design, D+ is the highest possible assigned overall grade.)

 

TAKE AWAY: Due to the nature of the design, the support for this intervention is weak. Nevertheless, the investigator provides a thoughtful guide for using music to facilitate turn taking with a Danish speaking child who did not show interest in interactions and did not signal communicative intent.

                                                                                                           

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?

• Case StudiesDescription with Pre and Post Test Results

  • Single Subject Experimental Design with Specific Client   

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

Level = D+                                                      

                                                                                                           

3. Was phase of treatment concealed?                                 

a. from participants? No

b. from clinicians? No

c. from data analyzers? No

 

4. Were the participants adequately described? No

a. How many participants were involved in the study? 1

b. The following characteristics/variables were described:

• age: 2 ½ years

• gender: M

• cognitive skills: moderate learning disabled  

• sensory skills: tended to be overwhelmed by sensory stimulation

4c. Were the communication problems adequately described? No

• The disorder types was language impairment.

• Other aspects of communication that were described included

— imitated and played with speech sounds

— did not display communicative intent

— did not point or show interest in give and take game

— had few words that were only spoken with mother

                                                                                                                       

5. Was membership in treatment maintained throughout the study? Not applicable, there was only one P.

a. If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable

b. Were any data removed from the study? No

 

6. Did the design include appropriate controls? No, this was a case study.

a. Were baseline/preintervention data collected on all behaviors? No, no baseline/preintervention data were provided.

b. Did probes/intervention data include untrained data? No, no probe /intervention data were provided.

c. Did probes/intervention data include trained data? No, no probe /intervention data were provided.

d. Was the data collection continuous? No, no probe /intervention data were provided.

e. Were different treatment counterbalanced or randomized? Not Applicable

 

7. Were the outcomes measure appropriate and meaningful? Unclear, the investigator’s definition of outcome measures were not clear but they appeared to be more closely tied to music than conversation.

a. The outcomes were

OUTCOME #1: To increase the rate of appropriate turn yielding and taking

OUTCOME #2: To improve preverbal and social skills

(continue numbering as needed)

 

 

8. Results:

a. Did the target behavior improve when it was treated? Yes

b. The overall quality of improvement for each of the outcomes is difficult to discern because the investigator did not provide sufficient data. The ratings listed below are estimates:

• OUTCOME #1: To increase the rate of appropriate turn yielding and taking–limited

• OUTCOME #2: To improve preverbal and social skills—limited

 

 

9. Description of baseline:

a. Were baseline data provided? No

 

10. What was the magnitude of the treatment effect? NA

 

 

 

11. Was information about treatment fidelity adequate? Not Provided

 

 

12. Were maintenance data reported?

 

 

13. Were generalization data reported? No

 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D-

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To explain and illustrate how music therapy and turn analysis can be used to improve preverbal and social skills.

 

POPULATION: language disorder (limited social and verbal communication); child

 

MODALITY TARGETED: production

 

 

ELEMENTS OF PROSODY USED AS INTERVENTION: music (rhythm, pauses, intonation, stress, pitch)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: turn taking

 

DOSAGE: 6 sessions (length and frequency were not specified)

 

ADMINISTRATOR: music therapist

 

MAJOR COMPONENTS:

 

• 6 sessions

 

– Session 1:

• C assisted P (for safety) as he bounced on a large physical therapy ball. This was an activity that P liked. C and P sat side-by-side in front of a mirror.

• While P was bouncing, C sang lines from familiar songs or sang descriptions of P’s actions.

• Occasionally, C would sing a line about stopping and would physically stop P’s bouncing.

• After a brief interval, C would sing a phrase indicating that C could begin bouncing again and allowed him to continue bouncing again.

 

– Session 2 and 3:

• During Session 2, P spontaneously vocalized in an excited manner with his vocalizations moving from one pitch to the next (glissando). When C attempted to join him, he stopped.

• When he next used glissando, C interrupted him and then handed the turn over to him by

1. singing a short (3 note) glissando ,

2. stressing the last note (a common strategy for yielding a turn in conversation),

3. C shortened P’s glissisandi by interrupting him at progressively shorter intervals.

4. P was allowed to keep bouncing during the glissandi work as long as he maintained attention or and his speech sounds were not “diffuse” (?, not sure what this is, pmh). In such cases, C sang the song directing him to stop and physically stopped him.

• During these sessions, C moved to the floor and asked P’s mother to hold him. C introduced the guitar playing a repetitious sequence of chords which provided a rhythm to replace the bouncing.

 

– Sessions 4, 5, and 6

• At this point, P was regularly using short 3 notes, sung in a “favorite” key, ending in a rising then falling terminal contour.

• C and P imitated speech sounds, included sounds that sounded like Danish words.

 

 


Wambaugh et al. (2012)

April 10, 2014

EBP THERAPY ANALYSIS for

Single Subject Designs

 

Note: The summary can be viewed by scrolling about two-thirds of the way down on this page.

 

SOURCE: Wambaugh, J., Nessler, C., Cameron, R., & Mauszycki, S. C. (2012). Acquired apraxia of speech: The effects of repeated practice and rate/rhythm control treatments on sound production accuracy. American Journal of Speech-Language Pathology, 21, S5- S27.

 

REVIEWER(S): pmh

 

DATE: April 7, 2014

 

ASSIGNED OVERALL GRADE:  A- (The highest possible grade is A-.)

 

TAKE AWAY: The focus of these single subject experimental design studies was primarily on repeated practice with investigators employing and analyzing rate/rhythm as a strategy to increase effectiveness after the primary intervention. Rate/rhythm intervention was successful in increasing the production of speech sound accuracy following repeated practice intervention.

 

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: Combined design—ABCA, multiple probe across behaviors, multiple baseline across Ps

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? No

 

 

4. Were the participants adequately described?  Yes

a. How many participants were involved in the study? 10

b.

– The following characteristics/variables were controlled: diagnosis of chronic apraxia of speech with nonfluent, agrammatic aphasia (Broca’s aphasia)

– The following characteristics were described:

• age: 33-60 years

• gender: 7m, 3f

• cognitive skills: WNL                 

• native language:   all English native speakers

• concurrent speech-language therapy: No

• psychosocial status: negative history for substance abuse, psychological disorders       

• neurological status: negative history with the exception of the stroke

• etiology: single stroke; all CVAs

• site of lesion: 9 Ps left hemisphere, 1 P right hemisphere; 8 middle cerebral artery, 1 anterior cerebral artery, 1 basal ganglia

• years post onset: 1 to 19 years

• handedness (premorbid): 6 right, 3 left, 1 ambidextrous

• years of education: 12 to 21 years

                                                 

c. Were the communication problems adequately described? Yes

• List the disorder type(s): of chronic apraxia of speech with nonfluent, agrammatic aphasia (Broca’s aphasia)

• List other aspects of communication that were described:

— hearing: WNL

— intelligibility: 68%- 96%

— overall PICA: 40- 71

— WAB aphasia quotient: 24.8 – 78

                                                                                                                       

 

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? No

 

 

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

c. Did probes/intervention data include trained data? Yes

d. Was the data collection continuous? Yes. There were 5 probe lists, some were continually measures, other were periodically measured.

e. Were different treatment counterbalanced or randomized? No, by design the repeated practice procedure was administered first, then the rate/rhythm procedure was administered.

 

 

7. Were the outcomes measure appropriate and meaningful? Yes

a. The outcomes were

  • OUTCOME #1: Improved production of P’s designated speech sounds in words (or for one P, sentences) during an imitation task.

• OUTCOME #2: Improved percentage of correct consonants (PCC) in words (or for one P, sentences) during an imitation task.

b. Both of the outcomes that are subjective.

c.  None of the outcomes were objective.

d. The data supporting reliability of outcomes is

• A measure of combined reliability across all lists and Ps that ranged from 83% to 97%; the average was 91%.

 

 

8. Results:

a. Did the target behavior improve when it was treated? Yes

b. Only data for OUTCOME #1 were statistically analyzes.

• Improvement for Repeated Practice Procedures:

– 8 of the 10 Ps improved, although the degree of improvement varied (Overall Quality—Moderately strong)

• Improvement for Rate/Rhythm Procedures (administered only when Ps did not achieve maximal gains from Repeated Practice Procedures):

– Limited gains were achieved for 6 of the 8 Ps who were treated with Rate/Rhythm Procedures.

 

9. Description of baseline:

a. Were baseline data provided? Yes

• OUTCOME #1: Improved production of P’s designated speech sounds in words (or for one P, sentences) during an imitation task—Because of the nature of the design, the number of baseline data varied across the 10 P but there was a minimum of 5 baseline data points for each P.

b. Was baseline low and stable?

•   OUTCOME #1: Improved production of P’s designated speech sounds in words (or for one P, sentences) during an imitation task—Generally the baseline was low and stable.

c. What was the percentage of nonoverlapping data (PND)? Not provided

 

 

10. What was the magnitude of the treatment effect.”

• OUTCOME #1: Improved production of P’s designated speech sounds in words (or for one P, sentences) during an imitation task.

– magnitude of effect: varied based on procedure, probe list, and P. Of those who made progress (8/10), d ranged from 0.78 – 16.47.

– measure calculated: d

– interpretation:  Strong improvement.

 

 

11. Was information about treatment fidelity adequate? Not Provided

 

 

12. Were maintenance data reported? Yes. For the 8 Ps who benefitted from the interventions, there was a strong tendency to maintain and even improve performance when assessed 4 and 8 weeks after the termination of therapy.

 

 

13. Were generalization data reported?Yes. Seven of the 8 Ps who improved evidenced generalization to untreated probe lists.

 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: A-

 

 

SUMMARY OF INTERVENTION

(summary is only concerned with the rate/rhythm intervention)

 

PURPOSE: The primary purpose was to investigate the effectiveness of repeated practice on the accuracy of production of speech sounds. The secondary purpose was to determine if the gains from repeated practice could be enhanced when repeated practice is followed by rate/rhythm intervention. (That is, repeated practice and rate/rhythm interventions were not compared.)

 

POPULATION: apraxia of speech and Broca’s aphasia

 

MODALITY TARGETED: production

 

ELEMENTS OF PROSODY USED AS INTERVENTION (part of independent variable: rate, rhythm

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: production of speech sounds

 

DOSAGE: 3 times a week, sessions (probes plus interventions) lasted 1.25 to 1.5 hours, number of sessions varied from about 23-45 sessions for combined treatment and approximately 9-20 sessions for rate/rhythm only

 

ADMINISTRATOR: SLP

 

STIMULI: auditory, motor/kinesthetic

 

MAJOR COMPONENTS:

 

1. C constructs sentence or word lists for the P taking into considerations P’s error patterns and the optimal overall length of stimuli (single words or sentences) and syllable patterns.

2. C models a targeted word or sentence for the P accompanied by hand tapping guided by the beat of a metronome. (The metronome was set a 50% of P’s customary rate of syllable production.)

3. C instructs P to repeat the target 5 times in succession.

4. C provides only general feedback about the acceptability of speech sound production, even if P requests for more specific information.

5. The procedure continues through each of the items on the target list.

6. C presents the target lists 3 times during the session.