Rosenbek et al. (2004)

EBP THERAPY ANALYSIS for

Single Subject Designs

 

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

 

Key:

C = Clinician

EBP = evidence-based practice

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

MMSE = Mini Mental Status Examination

WLN = within normal limits

 

SOURCE: Rosenbeck, J. C., Crucian, G. P., Leon, S. A., Hieber, B., Rodriguez, A. D., Holiway, B., Ketterson, T. U., Ciampetti, M., Heilman, K., & Gonzalez-Rothi, L. (2004). Novel treatments for expressive aprosodia: A phase I investigation of cognitive linguistic and imitative intervention. Journal of the International Neuropsychological Society, 10, 786-793.

 

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

 

DATE: 2009*

ASSIGNED OVERALL GRADE: A- (Based on the design of the investigation, the highest possible grade was A-.)

 

TAKE AWAY: Using single subject experimental designs, the investigators compared 2 approaches (cognitive-linguistic and imitative approaches) to treating expressive aprosodia. The results indicated that both approaches were effective in improving the rate of correct productions of 3 affects/emotions: happy, sad, angry. Another affect (fear) was probed as a control and never treated. The investigators provide thorough descriptions of both intervention procedures as well as the participant (P) characteristics.

                                                                                                                       

 

  1. What was the focus of the research? Clinical Research

  

    2.  What type of evidence was identified? 

• What type of single subject design was used? Case Studies– Single Subject Experimental Design with Specific Clients: ABAC

  •  What was the level of support associated with the type of evidence? Level = A-

                                                                                                            

  1. Was phase of treatment concealed?

•  from participants? No

• from clinicians? No

• from data analyzers? Yes

 

  1. Were the participants adequately described? Yes, the investigators provided thorough descriptions of the participants (P).

–  How many participants? 3

    –  The following characteristics controlled: all Ps were diagnosed with expressive aprosodia

–  The following characteristics described:

  • age: 49-83 years
  • gender: 2m; 1f
  • cognitive skills: Mini Mental Status Examination (MMSE) — 2Ps within normal limits (WLN); 1P mild cognitive impairment
  • visual spatial skills:

0.03%ile to 0.08%ile on the Rey-Osterieth Complex Figure Test

     – on the Judgment of Line Orientation test 1P WNL; 2Ps impaired

  • mood assessment:

     – Beck Hopelessness Scale = 2Ps WNL; 1P test score not reported

     – Geriatric Depression Scale = 1P WNL; 1P mild depression; 1P test score not reported

  • medications for depression: yes (2Ps); no (1P)
  • post onset: 4 months to 8 years
  • site of lesion: Right hemisphere damage confirmed by imaging and the investigators described lesions locations (2P); no imaging but P had left hemiplegia (1P)                                                   
  • educational level of participant: 10th Grade (1P); 12th Grade (2Ps)                                          

– Were the communication problems adequately described? Yes

  • The disorder type was Expressive Aprosodia
  • Other aspects of communication included

   – no or reduced modification of speaking rate, pause, pitch, and/or loudness: all 3 Ps

   – severity of expressive aprosodia: moderately severe (2Ps), severe (1P)

dysarthria: no signs of dysarthria (2Ps); mild dysarthria (1P)

– Ps’ concern about speech: none of the Ps reported concern

– Receptive Aprosodia: moderate problems (1P); mild problems (2P)

                                                                                                                       

  5.  Was membership in treatment maintained throughout the study? Yes

  •  If there was more than one participant, did at least 80% of the participants remain in the study? Yes
  • Were any data removed from the study? No

   6.  Did the design include appropriate controls? Yes

  • Were baseline/preintervention data collected on all behaviors? Yes
  • Did probes/intervention data include untrained data? Yes
  • Did probes/intervention data include trained data? Yes
  • Was the data collection continuous? Yes_
  • Were different treatment counterbalanced or randomized? Yes, but the randomization resulted in all 3Ps receiving cognitive-linguistic intervention first and imitation intervention second.

 

    7. Were the outcomes measure appropriate and meaningful? Yes

The outcomes were

OUTCOME #1: Percent correct production of targeted affects on treated and untreated probes

OUTCOME #2: Improved performance on an unpublished expressive aprosodia test battery

  • Both of the outcomes were subjective.
  • Neither of the outcomes were objective.
  • The investigators provided reliability measures:

OUTCOME #1: Percent correct production of targeted affects on treated and untreated probes

   – Intraobserver reliability: Kendall’s Tau = 0.75

   – Interobserver reliability: Kendall’s Tau = 0.79

  

   8. Results:

  • Did the target behavior improve when it was treated? Yes
  • b. The overall quality of improvement was

OUTCOME #1: Percent correct production of targeted affects on treated and untreated probes: overall improvement was moderate to strong

 OUTCOME #2: Improved performance on an unpublished expressive aprosodia test battery: improvement was moderate (increased 20%age points) to strong (increased 35%age points

     9. Description of baseline:

  • Were baseline data provided? Yes, the number of data points for each dependent variable/outcome was

OUTCOME #1: Percent correct production of targeted affects on treated and untreated probes: 8 data points each for baselines 1 and 2

OUTCOME #2: Improved performance on an unpublished expressive aprosodia test battery: 1 baseline measurement (actually, this is pre-test data)

 

  • Was baseline and stable?

OUTCOME #1: Percent correct production of targeted affects on treated and untreated probes

    – P1 = variable for baselines 1 and 2

   – P2 = low and stable for baselines 1 and 2

   – P3 = low and stable for baseline 1 and moderate for baseline 2

OUTCOME #2: Improved performance on an unpublished expressive aprosodia test battery—NA

 

     10. What was the percentage of nonoverlapping data (PND)

OUTCOME #1: Percent correct production of targeted affects on treated and untreated probes.

NOTE: The PNDs are approximate because they were derived from a visual inspection of the data (Figure 1). The PNDs were not calculated by the investigators and were not included in their results or discussion. As can be seen the PND data represent considerably lower qualities of improvement than the investigators’ interpretation in item #11.

  • P1:

– PND for therapy1 (cognitive linguistic) = 44% (unreliable ineffective)

– PND for therapy2 (linguistic) = 43% (unreliable ineffective)

  • P2:

– PND for therapy1 (cognitive linguistic) = 33% (unreliable ineffective)

– PND for therapy2 (linguistic) = 62% (questionable effectiveness)

  • P3:

– PND for therapy1 (cognitive linguistic) = 100% (highly effective)

– PND for therapy2 (linguistic) = 45% (unreliable ineffective)

 

     11.  What was the magnitude of the treatment effect?

  • P1:

– Effect size for therapy1 (cognitive linguistic) = 1.224 (large effect)

– Effect size for therapy2 (linguistic) = 1.183 (large effect)

  • P2:

– Effect size for therapy1 (cognitive linguistic) = 0.660 (moderate effect)

– Effect size for therapy2 (linguistic) = 2.542 (large effect)

  • P3:

– Effect size for therapy1 (cognitive linguistic) = 11.518 (large effect)

– Effect size for therapy2 (linguistic) = 2.015 (large effect)

 

  1. Was information about treatment fidelity adequate? Not Provided

 

 

  1. Were maintenance data reported? Yes
  • Maintenance for the 3Ps was limited following the first intervention (cognitive linguistic). For 2Ps, performance reverted to or was close to baseline. For 1P, performed continued to improve.
  • Following the second intervention (imitation), performance remained stable or regressed slightly.

 

 

  1. Were generalization data reported? Yes
  • The improved performance during training generalized to the treated affects using new sentences.
  • The improved performance for trained affects did not generalize to an untreated affect (fear). However, the production of the fear affect was rarely produced accurately throughout the investigation. Even during baseline, there were at least some productions of the other affects. This suggests that fear may be more difficult to produce (or perceive) accurately.

 

  1. Brief description of the design:
  • The investigators used 3 single-subject experimental designs (ABAC) to compare the effectiveness of 2 approaches (cognitive-linguistic and imitative) to treating expressive aprosodia:.
  • Each P was exposed to the following procedures:

– Baseline probes for 8 to 9 sessions (A)

– Experimental treatment #1 (B) which was the cognitive-linguistic approach. (Note: the order of treatments had been randomly determined. For all 3Ps the first treatment was determined to be the cognitive-linguistic approach.) Each session of the treatment involved:

  1. Probe of treated and untreated sentences and affects.
  2. Administration of the cognitive-linguistic intervention for approximately 1month/20 sessions
  3. Post treatment phase #1 of approximately 1 month. No intervention but with 2 probe sessions

– Baseline probes for 8 sessions (A)

– Experimental treatment #2 (C) which was the imitative approach. Each session of the treatment involved:

  1. Probe of treated and untreated sentences and affects.
  2. Administration of the imitative intervention for approximately 1 month/20 sessions.
  3. Post treatment phase #2 of approximately 1 month with not intervention but with 2 probe sessions
  • The baseline probes involved the production of sentences with the following affects: neutral, fear, happy, sad, and angry.
  • The treated affects were angry, happy, and sad.
  • The control affect was fear; that it, it was never treated.

 

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

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To compare two approaches (cognitive-linguistic and imitative) for treating expressive aprosodia.

POPULATION: Expressive Aprosodia, Right Hemisphere Brain Damage

 

MODALITY TARGETED: Production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: affect

DOSAGE: 1 hour, approximately 20 sessions over a month

 

ADMINISTRATOR: SLP

 

STIMULI: auditory, visual

GOAL ATTACK STRATEGY: vertical

 

MAJOR COMPONENTS:

 

  • Two treatment approaches were compared:

– Imitative technique

– Cognitive-Linguistic technique

 

  • For both approaches

– there was a 6-step continuum

– Step1 provided maximum support (cueing)

– Cueing was faded in subsequent steps

– Sessions involved 9 treatment sentences (3 happy, 3 sad, 3 angry)

– Sentences were presented in random order began with STEP 1 and continued to STEP 6.

  • To move the sentence to the next step, the P must produce 3 consecutive correct responses for that sentence.

– If a P could not progress through a step in 15 attempts, a new sentence was introduced.

  • The investigators provided a thorough description of each of the approaches in Table 3. Below is a summary of the steps for each treatment.

 

Imitative Treatment:

STEP 1:

  • C models a sentence using the target emotion. C also displays appropriate facial expression.
  • C and P repeat the target sentence with the targeted emotion in unison

STEP 2:

  • C models the target sentence with the appropriate prosody.
  • P produces the modeled sentence and prosodic affect.

STEP 3:

  • C models the target sentence with the appropriate prosody and covers his/her face with the sentence stimuli cards thus obstructing the P’s view of his/her facial expression.
  • P imitates the prosody and the sentence.

STEP 4:

  • C produces the sentence with a neutral prosody.
  • P produces the sentence with the prosody being treated in the previous 3 steps (i.e., happy, sad, or angry).

STEP 5:

  • C asks a question designed to elicit the target sentence and a specific affect.
  • For example, to elicit a happy (or sad or angry) affect for the sentence “The fair starts tomorrow,“ C will ask “Why are you so happy (or sad or angry?”)

STEP 6:

  • Using the same sentence, the C directs a role playing task in which the P shares a targeted affective/ emotional state with a family member.

Cognitive-Linguistic Approach

STEP 1:

  • C places a card describing a specific prosodic pattern in front of the P. The card does not list the name of the emotion
  • C directs P to read the description until he/she is ready to describe its content to the C.
  • If necessary, C can assist P by defining terms.

STEP 2:

  • C keeps the description of the prosodic pattern from Step1 on the table and adds 4 cards with the name of each of the emotions (emotion label cards).
  • C directs P to match the description to the proper emotion label card.
  • When P responds appropriately, C removes the extra emotion label name cards leaving only the prosody description and the appropriate emotion label card.
  • C then places cards with pictures depicting the facial expression associated with each of the 4 emotions.
  • P directs C to match the emotion label card with the appropriate picture. P should allow C sufficient time to consider all cards.
  • When P responds appropriately, C should remove card the extra emotion picture cards. That is, only the emotion facial picture card, emotion label card, and prosody description card should be on the table.
  • C directs P to describe in his/her on words, the prosody associated with the targeted emotion.

STEP 3:

  • C

– displays the target sentence,

– displays the emotion label card, emotion facial expression card, and the prosody description card for the emotion discussed in Steps 1 & 2,

– directs P to produce a sentence using the emotion listed on the emotion label card and its associated emotion facial picture card,

STEP 4:

  • C removes the prosody description card but retains the sentence card, emotion label card, and the emotion facial expression card.
  • C points to the sentence card and directs P to say the sentence using the prosodic pattern noted on the emotion label card and the emotion facial expression card.

STEP 5:

  • C removes the emotion label card but retains the sentence card and the emotion facial expression card.
  • C

– points to the sentence card and

– directs P to say the sentence using the prosodic pattern noted on the emotion facial expression card.

STEP 6:

  • C says the name of the target emotion.
  • C removes the emotion facial expression card,
  • C

– points to the target sentence and

– directs P to say the sentence.

*See Hargrove, P., Anderson, A., & Jones, J. (2009). A critical review of interventions targeting prosody. International Journal of Speech-Language Pathology, 11, 298-304. The current review was the basis for the analysis and summaries in that paper.

 

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