Ramig et al. (1994)

EBP THERAPY ANALYSIS

Treatment Groups

 

Note: Scroll about two-thirds of the way down the page to read the summary of the procedure(s).

 

Key:

C = Clinician

EBP = evidence-based practice

fo = fundamental frequency

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = Patient or Participant

PD = Parkinson’s disease

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE:  Ramig, L. O., Bonitati, C. M., Lemke, J. H., & Horii, Y. (1994). Voice treatment for patients with Parkinson disease: Development of an approach and preliminary efficacy data. Journal of Medical Speech-Language Pathology, 2, 191-209.

 

REVIEWER(S):  pmh

 

DATE: December 4, 2014

ASSIGNED GRADE FOR OVERALL QUALITY: C- (The highest possible grade was C due to the design of the investigation.)

 

TAKE AWAY: This is one of the earlier investigations documenting the effectiveness of Lee Silverman Voice Treatment (LSVT). The description of the intervention and the rationale for treatment procedures is more thorough than most descriptions of LSVT reviewed in this blog. The investigators presented evidence that significant differences occurred in speech measures of individuals with Parkinson’s disease (PD) immediately following LSVT:

– maximum duration of sustained vowel phonation

– fundamental frequency (f0) variability/range

– speech-language pathologist (SLP) rating of loudness, voice monotony, and intelligibility

– self rating of increase in loudness

– spousal rating of intelligibility.

In addition, the investigators statistically analyzed follow-up data 6 and 12 months after the initial 4-week training course. They determined progress was maintained with and without additional intervention.

 

 

  1. What type of evidence was identified?

                                                                                                           

  1. What was the type of evidence? Prospective, Single Group with Pre- and Post-Testing for the first phase of the study, and then 2 group (1 small subgroup did receive follow-up intervention, 1 group did not)

 

  1. Group composition
  2. If there were groups, were participants randomly assigned to groups? No
  3. If there were groups and participants were not randomly assigned to groups, were members of groups carefully matched? No
  4. If the answer to 2a and 2b is ‘no’ or ‘unclear,’ describe assignment strategy:
  • Assignment was based on the life style of the participants (Ps). Those who lived far away did not receive follow-up intervention during Phase 2 of the intervention.
  1. Was administration of intervention status concealed?
  2. from participants? No
  3. from clinicians? No
  4. from analyzers? No

                                                                    

 

  1. Were the groups adequately described? Yes
  2. How many participants were involved in the study?
  • total # of participant: 40
  • # of groups: 1 during Phase 1; 2 during Phase 2
  • # of participants in each group:

     – Phase 1, N = 40;

– Phase 2, N for Group 1 (received follow up intervention) = 13 or 8 (depending on length of follow up interventions); N for Group 2 (did not receive follow-up intervention) = 9 or 5 (depending on timing of follow assessments)

  • List names of groups:

     – Group 1 –received follow up intervention

– Group 2 — did not receive follow-up intervention

 

  1. The following variables were described
  • age: 53 to 86 years
  • gender: 30m, 10f
  • medications: 39/40 took anti-Parkinson medications; 8 Ps (20%) also took medication for other problems
  • residence: all residents of US.
  • diagnoses: all diagnoses of idiopathic Parkinson disease (PD); Stages of PD ranged from Stage I to IV.

 

  1. Were the groups similar before intervention began? Yes, the investigators statistically analyzed age and stage of PD and determined that there was no significant difference across sex of Ps.
  1. Were the communication problems adequately described? Yes
  • disorder types: common pretreatment symptoms

– reduced loudness (70%)

– imprecise articulation (58%)

– harsh and/or hoarse voice quality (35%)

– breathy voice quality (25%)

– bowed vocal folds (88%)

 

 

  1. Was membership in groups maintained throughout the study?
  2. Did each of the groups maintain at least 80% of their original members? Yes
  3. Were data from outliers removed from the study? No

 

  1. Were the groups controlled acceptably? No. Comparison of treatment groups was not possible for several outcomes.
  2. Was there a no intervention group? Yes
  3. Was there a foil intervention group? No
  4. Was there a comparison group? No
  5. Was the time involved in the foil/comparison and the target groups constant? Not Applicable

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes
  2. The outcomes were
  • OUTCOME #1:   Improved maximum vowel duration
  • OUTCOME #2:   Improved mean maximum vowel duration
  • OUTCOME #3:   Improved daily mean maximum vowel duration
  • OUTCOME #4:   Improved mean maximum fo range
  • OUTCOME #5:   Improved maximum fo range
  • OUTCOME #6:   Improved daily mean maximum fo range
  • OUTCOME #7:   Improved forced vital capacity
  • OUTCOME #8:   Improved slow vital capacity
  • OUTCOME #9: Improved perceived loudness by SLP
  • OUTCOME #10: Improved perceived monotonous voice by SLP
  • OUTCOME #11: Improved perceived intelligibility by SLP
  • OUTCOME #12: Improved perceived loudness by spouse
  • OUTCOME #13: Improved perceived monotonous voice by spouse
  • OUTCOME #14: Improved perceived intelligibility by spouse
  • OUTCOME #15: Improved self-perception of loudness by P
  • OUTCOME #16: Improved self-perception of monotonous voice by P
  • OUTCOME #17: Improved self-perception intelligibility by P
  1. The outcome measures that are subjective re
  • OUTCOME #9: Improved perceived loudness by SLP
  • OUTCOME #10: Improved perceived monotonous voice by SLP
  • OUTCOME #11: Improved perceived intelligibility by SLP
  • OUTCOME #12: Improved perceived loudness by spouse
  • OUTCOME #13: Improved perceived monotonous voice by spouse
  • OUTCOME #14: Improved perceived intelligibility by spouse
  • OUTCOME #15: Improved self-perception of loudness by P
  • OUTCOME #16: Improved self-perception of monotonous voice by P
  • OUTCOME #17: Improved self-perception intelligibility by P
  1. The outcome measures that are objective are
  • OUTCOME #1:   Improved maximum vowel duration
  • OUTCOME #2:   Improved mean maximum vowel duration
  • OUTCOME #3:   Improved daily mean maximum vowel duration
  • OUTCOME #4:   Improved mean maximum fo range
  • OUTCOME #5:   Improved maximum fo range
  • OUTCOME #6:   Improved daily mean maximum fo range
  • OUTCOME #7:   Improved forced vital capacity
  • OUTCOME #8:   Improved slow vital capacity

                                         

 

  1. Were reliability measures provided?
  2. Interobserver for analyzers? Yes:
  3. maximum duration of sustained vowel phonation (intraclass correlation = 0.99)
  4. maximum fo range (intraclass correlation = 0.94)
  5. fo analysis (intraclass correlation = 0.998)

 

  1. Intraobserver for analyzers? Yes:
  2. ratings of loudness by 2 SLPs (interclass correlation = 0.92)
  3. ratings of intelligibility by 2 SLPs (interclass correlation = 0.97)

 

  1. Intrasubject reliability? Yes:
  2. fo (interclass correlation = 0.99)
  3. semitone standard deviation (interclass correlation = 0.90)

 

  1. Treatment fidelity for clinicians? No, but only one SLP administered all sessions.

 

  1. What were the results of the statistical (inferential) testing?
  • All Ps were assessed prior to the beginning of therapy.
  • There were 3 sets of post data:

– post = data collected immediately following the termination of a 4 week course of therapy (N= 40)

– fu6 = follow-up data collected 6 months after the termination of the original 4 week course of therapy; Group 1 = Ps who continued treatment, Group 2 = Ps who did not continue treatment

– fu12 = follow-up data collected 12 months after the termination of the original 4 week course of therapy; Group 1 = Ps who continued treatment, Group 2 = Ps who did not continue treatment

  • The number in each of the subgroupings varied relative to type and timing of post measures. The numbers will be noted below.

PRE VERSUS POST MEASURES

  • Some Outcomes (#3, #6, #9 through #17), which are listed below as a reminder to the reader, were only compared on pre and post measures. Not all the outcomes involved the same number of Ps; therefore, the N for each comparison is listed after each outcome. If there was a significant difference between the pre and post test, an asterisk follows the number of Ps in parentheses.
  • OUTCOME #3: Improved daily mean maximum vowel duration (N = 28)*
  • OUTCOME #6: Improved daily mean maximum fo range (N = 28)*
  • OUTCOME #9: Improved perceived loudness by SLP (N = 9)*
  • OUTCOME #10: Improved perceived monotonous voice by SLP (N = 9)*
  • OUTCOME #11: Improved perceived intelligibility by SLP (N = 9)*
  • OUTCOME #12: Improved perceived loudness by spouse (N = 14)
  • OUTCOME #13: Improved perceived monotonous voice by spouse (N = 14)
  • OUTCOME #14: Improved perceived intelligibility by spouse (N = 14)
  • OUTCOME #15: Improved self-perception of loudness by P (N = 27)*
  • OUTCOME #16: Improved self-perception of monotonous voice by P (N = 27)
  • OUTCOME #17: Improved self-perception intelligibility by P (N =27)*
  • Outcomes #1, 2, 4, 5, 7, and 8 (listed below as a reminder to the reader) were first compared on pre and post measures for the entire group. Due to technical/scheduling problems, not all the outcomes involved the same number of Ps. Therefore, the N for each comparison is listed after each outcome. If there was a significant difference between the pre and post test, an asterisk follows the number of Ps in parentheses.

– OUTCOME #1:   Improved maximum vowel duration (N = 40)*

– OUTCOME #2:   Improved mean maximum vowel duration (N = 40)*

– OUTCOME #4:   Improved mean maximum fo range (N = 37)*

– OUTCOME #5:   Improved maximum fo range (N = 37)*

– OUTCOME #7:   Improved forced vital capacity (N = 38)

– OUTCOME #8:   Improved slow vital capacity (N = 38)

PRE VERSUS POST, FU6, AND FU12 DATA

  • The investigators explored maintenance issues by administering follow-up tests 6 and 12 months after the initial 4-week course of therapy. See #11 for further discussion.
  1. What was the statistical test used to determine significance? ANOVA

 

  1. Were confidence interval (CI) provided? No

 

                                   

  1. What is the clinical significance? NA

 

 

  1. Were maintenance data reported? Yes
  • Outcomes #1, 2, 4, and 5 (listed below as a reminder to the reader) were compared on pre and follow-up measures:

– post and 6 month follow-up (fu6) or

– post and fu6 and 12 month follow up (fu12.)

  • Some Ps agreed to 6 or 12 months of extended intervention, some did not but agreed to follow-up testing at 6 months or 6 and 12 months.
  • Due to scheduling problems, not all the comparisons involved the same number of Ps. Therefore, the N for each comparison is listed after each outcome.
  • OUTCOMES #1 and #2: Improved maximum vowel duration and Improved mean maximum vowel duration

– N for group that received 6 months of additional intervention = 13

– N for group that did not receive 6 months of additional intervention but agreed to additional testing at 6 months = 11

– N for group that received 12 months of additional intervention and agreed to follow up testing at 6 and 12 months = 7

– N for group that did not receive additional intervention but agreed to additional testing at 6 and 12 months = 8

– Summary of findings for these outcomes:

  1. There was no significant difference between those who received additional intervention and those who did not.
  2. Both extra intervention and no extra intervention treatment groups improved from the initial post test to the follow-ups.
  • OUTCOMES #4 and #5: Improved mean maximum fo range and Improved maximum fo range

– N for group that received 6 months of additional intervention = 13

– N for group that did not receive 6 months of additional intervention but agreed to additional testing at 6 months = 11

– N for group that received 12 months of additional intervention and agreed to follow up testing at 6 and 12 months = 7

– N for group that did not receive additional intervention but agreed to additional testing at 6 and 12 months = 8

– Summary of findings for these outcomes:

  1. There was no significant difference between those who received additional intervention and those who did not.
  2. Neither extra intervention nor no extra intervention treatment groups improved noticeably from the initial post test to the follow-ups.

 

  1. Were generalization data reported? No

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C-

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of a treatment intervention (LSVT) for improving the speech of individuals with Parkinson disease.

POPULATION: Parkinson’s Disease; Adult

 

MODALITY TARGETED: Expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: duration, pitch variability, intonation, loudness

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness, duration, pitch variability

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: respiration/vital capacity (this did not improve), intelligibility

DOSAGE: 50 to 60 minute sessions, 4 times a week, for a month (initial intervention)

 

ADMINISTRATOR: SLP (the same SLP administered all the sessions_

 

STIMULI: auditory

 

MAJOR COMPONENTS:

  • This is an intensive intervention. (See dosage.)
  • Sessions usually include:
  1. Maximum phonation drills. The clinician (C) encourages the P to expend maximum phonatory effort by increasing loudness, duration, and pitch range of targets.
  2. When C judges that the P is producing targets with sufficiently loud voice, the C switches the target to functional speech used in daily living.
  3. C focuses on facilitating P’s continued maximum loudness and effort throughout the session.

 

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