Pennington et al. (2009)

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e. Did the potential sources include unpublished studies?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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