Jalled et al. (2000)

July 31, 2014

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

 

NOTE: The summary of the intervention procedures can be viewed by scrolling about two-thirds of the way down this page.

 

KEY:

AMRT = Arabic Melodic and Rhythmic Therapy, an Arabic adaptation of Melodic and Rhythmic Therapy

C = clinician

MIT = Melodic Intonation Therapy

MRT = Melodic and Rhythmic Therapy, a French adaptation of MIT

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist or equivalent

 

Source: Jalled, F., Skik, H., & Mrabet, A. (2000). Arabic melodic and rhythmic therapy: A method of severe aphasia therapy. Neurosciences, 5 (2), 91- 93.

 

Reviewer(s):  pmh

 

Date: July 31, 2014

 

Level of Evidence: F = Expert Opinion, no supporting evidence for the effectiveness of the intervention although the author may provide secondary evidence supporting components of the intervention.

 

Take Away: The authors describe a Tunisian Arabic adaptation (AMRT) of Melodic and Rhythmic Therapy (MRT) which is a French adaptation of Melodic Intonation Therapy (MIT). The authors provided the linguistic basis of the modifications, procedures for the AMRT, and a summary of some research supporting AMRT.

 

  1. Was there review of the literature supporting components of the intervention? Narrative Review

 

  1. Were the specific procedures/components of the intervention tied to the reviewed literature? No

 

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

 

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

 

  1. Description of outcome measures:

List the outcome measure(s). List (add additional numbers if necessary):

  • Outcome: To speak using natural prosody while producing spontaneous utterances.

 

  1. Was generalization addressed? Yes

 

  1. Was maintenance addressed? No

 

 

SUMMARY OF INTERVENTION

 

Description of Intervention —Arabic Melodic and Rhythmic Therapy (ARMT)

 

POPULATION: Aphasia; Adults

— The authors recommended that the following characteristics are associated with good progress:

  • site of lesion- anterior portion of the left hemisphere;
  • reduced expressive language with speech sound disorders;
  • intact comprehension;
  • lack anosognosia and/or auditory reception disorders;
  • no emotional lability

 

TARGETS:

  • to produce short, intelligible, and informative sentences with a natural prosody,
  • to imitate sentences accurately,
  • to produce 2-3 word sentences
  • to describe pictures
  • to answer questions

 

TECHNIQUES:

 

STIMULI: auditory, rhythmic

 

DOSAGE: varies average duration of therapy was 3 to 4 months

 

ADMINISTRATOR: SLP

 

PROCEDURES:

 

  • There are 3 stages for this intervention which begin as nonverbal and end in multiword utterances.

 

  • Stage I:

— C taps rhythms that are initially rhythmic and later varied and directs P to listen.

— C continues tapping but then asks P to imitate the rhythms. First there is a relatively long latency and then P gradually reduces the latency so that the tapping is conversation-like.

— C then adds humming (2 notes high and low) to the stimuli and P is expected to imitate the humming too. This exercise evolves in chant-like vocalizations

 

  • Stage II:

— C develops a corpus appropriate to Tunisian Arabic melody, rhythm, and stress. Utterances range from single words to sentences with varying length and complexity. The vocabulary is appropriate to daily living in Tunisia, although the authors did develop a corpus appropriate for educated Ps.

— C produces utterances and P listens.

— C directs P to imitate the utterance, gradually increasing length and complexity of the utterances to be modeled and gradually reducing P support. The target for acceptable production is all the elements of the model with the exception of articulatory accuracy.

 

  • Stage III:

— C introduces a question/answer activity in which the target is the natural use of prosody in spontaneous conversation.

 

RATIONALE/SUPPORT FOR INTERVENTION:

  • In the Introduction, the components of the intervention and its rationale are supported logically. In the discussion, the authors summarize some research about TMR and provide anecdotal information about their Ps.

 

CONTRAINDICATIONS FOR USE OF THE INTERVENTION:

  • None provided.

 

 


Lee (2008)

July 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.

Key:
ADHD = Attention Deficit Hyperactivity Disorder
ASD = Autism Spectrum Disorder
C = Clinician
Nan-Hu = a traditional, 2 string musical instrument
P = participant or patient
pmh = Patricia Hargrove, blog developer

SOURCE: Lee, L. L. (2008). Music enhances attention and promotes language ability in young special needs children. In L. E. Schraer-Joiner & K. A. McCord (Eds.), Selected Papers from the International Seminars of the Commission on Music in Special Education, Music Therapy, and Music Medicine (pp. 34- 45). Malvern, Victoria, Australia. Malvern, Victoria, Australia: International Society for Music Education.
Paper—http://issuu.com/official_isme/docs/2006-2008_specialed_proceedings/41

REVIEWER(S): pmh

DATE: July 2, 2014

ASSIGNED OVERALL GRADE: B- (The highest possible grade was A- because of the experimental design of the investigation.)

TAKE AWAY: This multiple baseline investigation demonstrates the effectiveness music therapy in improving attention and language in developmentally delayed children from Taiwan who were speakers of Mandarin Chinese. The investigator provided a clear description of the phases of treatment.

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 Clients:- Multiple Baseline
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? No
a. How many participants were involved in the study? 3
b. The following characteristics were described
• age: 4 to 5 years
• gender: 2 m; 1 f
• cognitive skills: all developmental delays and one each of ASD, ADHD, and Down syndrome
• expressive language: at baseline—“no language ability (1P); no words (1P); did not want to speak and speech was unclear (1P)
c. Were the communication problems adequately described? Yes___ No _x__
• List the disorder type(s): language impairment, speech sound impairment
• List other aspects of communication that were described:
–At baseline, the author described the expressive language of each of the P’s”
– “no language ability (1);
– no words (1);
– did not want to speak and speech was unclear (1)

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? Varied. I would have liked to see data describing change or lack of change when a target was not being treated (other than baseline). Figure 2 may have contained some of this information but I needed more explanation of the figure.
a. Were baseline data collected on all behaviors? Yes
b. Did probes data include untrained data? Yes
c. Did probes data include trained data? No
d. Was the data collection continuous? Unclear, some data were collected throughout the investigation (Figure 2) but I could not interpret them. For example, I was not sure what the target objectives during baseline were and I did not know what the 1-8 scale represented. Also, I think the investigator only collected data on an outcome/target during the time it was targeted in intervention.
e. Were different treatment counterbalanced or randomized? Not Applicable, there was only one treatment.

7. Were the outcomes measure appropriate and meaningful? Yes
a. The outcomes of interest were
OUTCOME #1: Improve attention span
OUTCOME #2: Produce speech sounds
OUTCOME #3: Produce words
OUTCOME #4: Produce simple sentences
b. All of the outcomes were subjective.
c. None of the outcomes were objective.
d. All of the outcome measures were supported by reliability data.
e. The interobserver reliability data supporting each outcome measure–
OUTCOME #1: Improve attention span = .8691
OUTCOME #2: Produce speech sounds = .8444
OUTCOME #3: Produce words = .7619
OUTCOME #4: Produce simple sentences = .9096

8. Results:
a. Did the target behavior improve when it was treated? Yes
b. The overall quality of improvement was
OUTCOME #1: Improve attention span—all Ps improved markedly from pre to posttest (i.e., strong improvement)
OUTCOME #2: Produce speech sounds—all Ps improved markedly from pre to posttest (i.e., strong improvement)
OUTCOME #3: Produce words—all Ps improved markedly from pre to posttest (i.e., strong improvement)
OUTCOME #4: Produce simple sentences—all Ps improved markedly from pre to posttest (i.e., strong improvement)

9. Description of baseline:
a. Were baseline data provided? Yes
Because the baselines were staggered, each P had a different number of baselines.
P1: 4 sessions
P2: 6 sessions
P3: 8 sessions
(continue numbering as needed)

b. Was baseline low (or high, as appropriate) and stable? (The numbers should match the numbers in item 7a.)
OUTCOME #1: Improve attention span—low, stability not described
OUTCOME #2: Produce speech sounds—low, stability not described
OUTCOME #3: Produce words—low, stability not described
OUTCOME #4: Produce simple sentences—low, stability not described

c. What was the percentage of nonoverlapping data (PND)? Not applicable, insufficient data.

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

11. Was information about treatment fidelity adequate? Not Provided

12. Were maintenance data reported? No

13. Were generalization data reported? Yes. Baseline data were collected by observers in the classroom. Ps improved markedly on all outcomes from pre to post test which were administered by a pediatric physician.

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

SUMMARY OF INTERVENTION

PURPOSE: to investigate the effectiveness of music therapy on attention and language production in speech needs children

POPULATION: developmental delay, language impairment, speech sound impairment (Mandarin Chinese)

MODALITY TARGETED: expressive

ELEMENTS OF PROSODY USED AS INTERVENTION: rhythm (music)

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: vocalization, speech sounds, single words, simple sentences

OTHER TARGETS: attention

DOSAGE: 20 weeks, one hour per week

ADMINISTRATOR: Music Therapist

STIMULI: musical instruments, recorded music,

MAJOR COMPONENTS:

• Four phases of intervention:
1. Improving attention
2. Sound making/vocalizing
3. Producing single words
4. Producing simple sentences

• Overview of intervention:
– Prior to the intervention, the investigator administered baseline sessions and provided a free play session in which each P was allowed to select a favorite musical instrument.
– Each P selected a different instrument: rattles, drums, and hand bells.

• Phase1. Improving attention
– Goal: facilitate attention using musical instruments
– Steps:
1. Hello Song (C played a guitar song at the beginning of each session)
2. Attendance Song (C played P’s favorite instrument)
3. Musical Story Telling (C told story with sound effect instruments)
4. Relaxation Period (C played instrumental music which she had recorded)
5. Goodbye Song (C played a guitar song at the end of each session).

• Phase 2. Sound making/vocalizing
– Goal: facilitate the production of speech sounds (vocalizations)
– Steps:
1. Hello Song (C played and sung a guitar song and encouraged P to imitate the singing by vocalizing.)
2. Attendance Song (C played P’s favorite instrument. C encouraged P to imitate the instrument vocally.)
3. Sound Games [C played the Nan-Hu and encouraged P to imitate by vocalizing. C also played wind instruments (e.g., recorder, slide-whistle) and encouraged P to vocalize using approximations of lip shapes.]
4. Relaxation Period (C played soft music while P attempted to rest.)
5. Good-bye Song [C played a guitar song and sang a “soft sound song” (?) at the end of each session].

• Phase 3. Producing single words
– Goal: facilitate the production of single word utterances
– Steps:
1. Hello Song (C played and sung a guitar song and encouraged P to imitate a single word.)
2. Attendance Song (C played P’s favorite instrument. C encouraged P to imitate the instrument vocally using at least a single sound.)
3. Sound Games (C played the Nan-Hu and encouraged P to imitate the instrument and produce nonsense sounds.)
4. Relaxation Period (C played the guitar and sang a lullaby while P attempted to rest.)
5. Good-bye Song (C played a guitar song at the end of each session and P produced a single word from the song).

• Phase 4. Producing simple sentences
– Goal: facilitate the production of simple sentences
– Steps:
1. Hello Song (C played and sung a guitar song and encouraged P to imitate a simple greeting phrase.)
2. Attendance Song [C played P’s favorite instrument and sang a song. P produced a phrase (“Here I am”) in response to a prompt in the song.]
3. Singing Activities, Movement and Musical Storytelling [C played a variety of instruments (e.g., recorder, slide-whistle, sound effect instrument, bells, etc.) while telling a story. C encouraged P to imitate and then produce simple sentences.]
4. Relaxation Period (C played recorded soft music while P attempted to rest.)
5. Good-bye Song (C played a guitar song at the end of each session and P produced a simple greeting such as “See you” or “Good-bye”).


McCann & Peppé (2003)

July 19, 2014

NATURE OF PROSODIC DISORDERS
ANALYSIS FORM

Note: Key–
AS = Asperger’s syndrome
ASD = Autism Spectrum Disorder
Nongrammatical pauses = hesitation or intraphrase pauses
P = participant
pmh = Patricia Hargrove, the blog developer
TD = typically developing

SOURCE: McCann, J., & Peppé, S. (2003). Prosody in autism spectrum disorders: A critical review. International Journal of Language and Communication Disorders, 38, 325-350.

REVIEWER(S): pmh

DATE: July 13, 2014

ASSIGNED GRADE FOR OVERALL QUALITY: B (The highest possible grade was B. This well written critical review had many, but not all, qualities of a classic systematic review.)

POPULATION: Autism Spectrum Disorders (ASD)

PURPOSE: to review the extant literature to determine if there is evidence for a prosodic disorder among speakers with autism including High Functioning Autism (HFA) and Asperger’s syndrome (AS)

INSIGHTS ABOUT PROSODY:
• The authors were not able to identify a single prosodic disorder or patterns of disordered prosody in their critical review of the research concerned with ADS.
• In fact, there was considerable variability, or even conflict, among the existing research.
• The authors suggested that this could be due, at least in part, to methodological differences.
• The authors reviewed research concerned with expressive and receptive prosodic function (stress, phrasing/chunking, affect) and form (intonation patterns), prosodic change, neurological processing of prosody, and echolalia.

1. What type of evidence was identified? Systematic Review

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
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: internet based databases
d. Did the sources involve only English language publications?
e. Did the 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? No
h. Did the reviewers describe procedures used to evaluate the validity of each of the sources? No
i. Was there evidence that a specific, predetermined strategy was used to evaluate the sources? No
j. Did the reviewers or review teams rate the sources independently? No
k. Were interrater reliability data provided? No
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? No
n. Were assessments of sources sufficiently reliable? Unclear
o. Was the information provided sufficient for the reader to undertake a replication? No
p. Did the sources that were evaluated involve a sufficient number of participants? No, for the most part.
q. Were there a sufficient number of sources? Yes (overall but not for the specific aspects of prosody)

2. Description of outcome measures:
• Outcomes Associated with stress:
– PRODUCTION OUTCOMES–contrastive stress in conversation, contrastive stress in an elicited task; sentence stress in an elicited task; number and accuracy of stressing in read and imitated sentences; sentence, contrastive, and lexical stress in conversation
– RECEPTIVE OUTCOMES–lexical stress
• Outcome Associated with phrasing/chunking: placement of boundaries in spontaneous speech, occurrence of grammatical and nongrammatical pauses in narratives, occurrence of nongrammatical pauses in reading and imitation, phrasing errors in spontaneous speech, comprehension of grammatical phrasing
• Outcome Associated with affect: judgment of affect of sentences, judgment of excited or calm state in sentences
• Outcome Associated with intonation patterns: frequency range, terminal fall, intonation contour, declination effect, and covariance of frequency and intensity of spontaneous declarative sentences, differentiation of minimal pair sentences as declarative or interrogative
• Outcomes Associated with prosodic change: preference for one of 4 readings differing in prosody
• Outcome Associated with neurological processing of prosody: P3 responses on an EEG, location of processing using fMRI
• Outcome Associated with echolalia: communicative function of prosody in echolalia

3. Description of results:

a. What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? (Place an X next to all that apply) NA, the authors did not provide EBP measures

b. Summarize overall findings of the secondary review:
• The findings from the different sources were contradictory.
• In addition, differences in participant characteristics, elicitation contexts, and dependent measures make it difficult to identify prosodic patterns associated with ASD.
• Nevertheless, speakers with ASD appear to struggle with all forms of stressing- lexical, sentence, and contrastive. Studies concerned with the pausing aspect of phrasing/chinking, affect, and intonation are sparse and contradictory.
• The results for the various measures of prosody were
1. Outcomes Associated with stress:
– PRODUCTION OUTCOMES—
• contrastive stress in conversation (atypical),
• contrastive stress in an elicited task (double the number of misassignments of stress—most likely to be excess stresses);
• sentence stress in an elicited task (not significantly different from TD peers);
• number and accuracy of stressing in read and imitated sentences (more misassignments);
• sentence (lower than TD), contrastive (lower than TD), and lexical (lower than TD) stress in conversation
– RECEPTIVE OUTCOMES–lexical stress (HFA lower scores)

2. Outcome Associated with phrasing/chunking:
– placement of boundaries in spontaneous speech (grammatical pauses were similar to TD peers and ASD Ps used fewer nongrammatical or hesitation pauses),
– occurrence of grammatical and nongrammatical pauses in narratives (grammatical pauses were similar to TD peers and ASD Ps used fewer nongrammatical or hesitation pauses),
– occurrence of nongrammatical pauses in reading (more likely to add nongrammatical pauses) and imitation (trouble imitating chunking/phrasing pattern),
– phrasing errors in spontaneous speech (40% of ASD Ps exhibited phrasing/chunking errors but this may have represented dysfluencies),
– comprehension of grammatical phrasing (HFA Ps performed more poorly than TD peers)

3. Outcome Associated with affect:
– judgment of affect of sentences (adult ASD and HFA Ps performed more poorly than typical peers),
– judgment of excited or calm state in sentences (HFA and TD peers were highly successful on this task)

4. Outcome Associated with intonation patterns:
– frequency range (although Ps with AS were not significantly different from TD peers, their ranges tended to be very narrow or very broad). The authors did not report on the following measures terminal fall, intonation contour, declination effect, and covariance of frequency and intensity of spontaneous declarative sentences;
– differentiation of minimal pair sentences as declarative or interrogative (in reading, interrogatives of Ps with AS sounded like declaratives; imitation was better than reading for Ps with AS but their performance was correlated with severity of AS and sentence length)

5. Outcomes Associated with prosodic change: preference for one of 4 reading differing in prosody [prerformed like TD children and children with cognitive impairments. That is, Ps with ASD did not display a preference among the following reading styles—natural, monotone, staccato, and metronome (monotone and unstressed)].

6. Outcome Associated with neurological processing of prosody:
– P3 responses on an EEG (adults with ASD did not differ from typical adults)
– location of processing using fMRI (specific areas of activation differed for linguistic but not affective prosody)

7. Outcome Associated with echolalia: communicative function of prosody in echolalia (in a case study a young P with HFA tended to echo prosody and segments when asked a question)

c. Were the results precise? No
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?
g. Were the results in the same direction? No
h. Did a forest plot indicate homogeneity? Not Applicable
i. Was heterogeneity of results explored? Yes
j. Were the findings reasonable in view of the current literature? Yes
k. Were negative outcomes noted? Yes

4. Were maintenance data reported? Not Applicable

5. Were generalization data reported? Not Applicable


Ziegler et al. (2010)

July 7, 2014

SECONDARY REVIEW CRITIQUE
Notes:
1. To view description of procedures, scroll about two-thirds of the way down on the page.
2. Key: C = Clinician; P = Participant or Patient; pmh = Patricia Hargrove

Source: Ziegler, W., Aichert. I., & Staiger, A. (2010). Syllable- and rhythm-based approaches in the treatment of apraxia of speech. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 59-66. doi:10.1044/nnsld20.3.59

Reviewer(s): pmh

Date: July 6, 2014

Overall Assigned Grade: D- d

Level of Evidence: D

Take Away: Evidence from learning studies and intervention studies concerned with procedures for improving the speech sound production of speakers with apraxia (AOS) are reviewed. Only the procedure concerned with using prosody (naturalistic rhythmic cueing) is described in this critique. Speech sounds, rate, and fluency improved following the intervention.
What type of secondary review? Narrative 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: The authors did not describe the search strategy.
d. Did the sources involve only English language publications? No
e. Did the 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? No
h. Did the reviewers describe procedures used to evaluate the validity of each of the sources? No
i. Was there evidence that a specific, predetermined strategy was used to evaluate the sources? No
j. Did the reviewers or review teams rate the sources independently? No
k. Were interrater reliability data provided? No
l. If the reviewers provided interrater reliability data, list them: NA
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? No
p. Did the sources that were evaluated involve a sufficient number of participants? Variable
q. Were there a sufficient number of sources? No

2. Description of outcome measures:
• Outcomes Associated with Procedure #1—Metrical Pacing Therapy (MPT; Brendel & Ziegler, 2008): segmental errors, rate, and fluency (p.64)

3. Description of results:
a. What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? NA

b. Summary of the overall findings of the secondary review:
• Rhythm intervention for AOS can improve not only rate and fluency but also speech sounds.
• Specifically,
— for speech sound errors–MPT improved significantly but not significantly better than the control (traditional treatment) group,
— for rate—MPT significantly improved and was significantly better than the control group
— for fluency— MPT significantly improved and was significantly better than the control group

c. Were the results precise? No
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? Not Applicable, only one study reviewed.
g. Were the results in the same direction? Not Applicable, only one study reviewed.
h. Did a forest plot indicate homogeneity? Not Applicable
i. Was heterogeneity of results explored? Not Applicable, only one study reviewed.
j. Were the findings reasonable in view of the current literature? Yes
k. Were negative outcomes noted? No

4. Were maintenance data reported? No. However, the authors of the review noted that the investigators in the reviewed source explored maintenance.

5. Were generalization data reported? No

SUMMARY OF INTERVENTION

Population: Apraxia of Speech; Adults

Prosodic Targets: rate, fluency

Nonprosodic Targets: speech sound errors

Aspects of Prosody Used in Treatment of Nonprosodic Targets: rhythm, rate

Description of Metrical Pacing Therapy (MPT; Brendel & Ziegler, 2008)
• Using earphones C presented rhythmic sequences representing typical speaking rhythms (i.e., templates).
• P listened to the rhythms using earphones.
• P then produced target words or phrases (depending on the functional level of the P) in unison with the rhythms from the earphones.
• P received visual feedback with an visual acoustical representation of the acoustics of both the template and P’s production.
• C modified the targets based on each P’s skills with respect to rate as well as the length and complexity.

Evidence Supporting MPT Procedure
— for speech sound errors–MPT improved significantly but not significantly better than the control (traditional treatment) group,
— for rate—MPT significantly improved and was significantly better than the control group
— for fluency— MPT significantly improved and was significantly better than the control group

Evidence Contraindicating MPT: none