Sapir et al. (2003)

EBP THERAPY ANALYSIS for

Single Subject Designs

 

Note: The summary of the intervention procedure(s) can be viewed by scrolling about 90% of the way down on this page.

 

Key:

C = Clinician

EBP = evidence-based practice

EI = ease of understanding/intelligibility

PIW/EI = the Percentage of Intelligible Words divided by Ease of Understanding/Intelligibility

Fo = fundamental frequency

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

PIW = percentage of intelligible words (PIW)

SD = standard deviation

SLP = speech–language pathologist

SPL = sound pressure level

STSD = standard deviation of fundamental frequency in semitones

WNL = within normal limits

 

 

SOURCE: Sapir, S., Spielman, J., Ramig. L. O., Hinds, S., Countryman, S., Fox, C., & Story, B. (2003). The effects of intensive voice treatment (the Lee Silverman Voice Treatment [LSVT]) on ataxic dysarthria: A case study. American Journal of Speech-Language Pathology, 12, 387-399.

 

REVIEWER(S): pmh

 

DATE:  March 16, 2015

ASSIGNED OVERALL GRADE: D+   (Highest possible grade based on design of investigation is D+.)         

 

TAKE AWAY: This case study presented evidence of the effectiveness of Lee Silverman Voice Treatment (LSVT) in improving loudness, intonation, rate, intelligibility articulation, and social functioning of a patient (P) with ataxic dysarthria.

                                                                                                           

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

 

 

  1. What type of evidence was identified?
  • What type of single subject design was used? Case StudyDescription with Pre and Post Test Results

                                                                                                           

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

                                                                                                           

  1. Was phase of treatment concealed?
  • from participants? No
  • from clinicians? No

from data analyzers? Yes, for many of the outcome

 

  1. Were the participants adequately described? Yes

How many participants were involved in the study? 1

– The following characteristics/variables were actively described:

  • age: 48 years
  • gender: F
  • cognitive skills: within normal limits (WNL) by self report
  • language skills: WNL by self report
  • hearing: WNL by self report
  • previous speech-language therapy: None
  • medication: stable up to and during the intervention
  • etiology: cerebellar dysfunction secondary to iatrogenically induced (gastric repartitioning surgery) thiamine deficiency encephalopathy” (p. 388)

– Were the communication problems adequately described? Yes

– The disorder type was ataxic dysarthria.

– Other aspects of communication that were described include

  • slow rate
  • articulatory breakdowns
  • problems with lip movement
  • reduced range of movement of tongue
  • Alternating Motion Rates (AMR) and Sequential Motion Rates (SMR) were slow, with some arhythmicity, and weak closure.
  • weak voice quality
  • inconsistent breathiness
  • intonation (pitch patterns) were inappropriate and limited in range
  • overall impairment judged to be moderate

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Not applicable, there was only on participant (P.)
  • If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable
  • Were any data removed from the study? No

 

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

                                                                      

  • 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? No
  • Were different treatment counterbalanced or randomized? Not Applicable

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes
  • The outcomes were

OUTCOME #1: Improved sound pressure level (SPL) in sustained vowels

OUTCOME #2: Improved SPL in the Rainbow Passage

OUTCOME #3: Improved SPL in the description of a picture

OUTCOME #4: Improved SPL in a monologue

OUTCOME #5: Improved SPL in specific sentences

OUTCOME #6: Improved mean fundamental frequency (Fo) for the Rainbow Passage

OUTCOME #7: Improved mean Fo for the description of a picture

OUTCOME #8: Improved mean Fo in a monologue

 

OUTCOME #9: Improved mean Fo in specific sentences

OUTCOME #10: Improved Fo standard deviation (SD) for the Rainbow Passage in semitones (STSD)

OUTCOME #11: Improved STSD in the description of a picture

OUTCOME #12: Improved STSD in a monologue

OUTCOME #13: Improved STSD for specific sentences

OUTCOME #14: Increased overall vowel formant triangle

OUTCOME #15: Increased overall vowel formant dynamics (i.e., increased formant frequency SD from their means

OUTCOME #16: Increased vowel formant triangle of specific vowels

OUTCOME #17: Improved rating of intonation by speech-language pathology blinded graduate students.

OUTCOME #18: Improved rating of articulatory precision by speech-language pathology blinded graduate students.

OUTCOME #19: Improved intelligibility as represented by the percentage of intelligible words (PIW) in words

OUTCOME #20: Improved intelligibility as represented by the ease of understanding (EI) as measured on a 1 (easy) to 5 (difficult scale)

OUTCOME #21: Increased PIW to EI ratio (PIW/EI)

OUTCOME #22: Improved rating on the Minnesota Improved Satisfactoriness Scales by the participant’s (P) supervisor in her volunteer position

OUTCOME #23: Improved self-perception of P of her communication, socialization, and work skills.

OUTCOME #24: Decreased rate of speech

  • The following outcomes are subjective:

OUTCOME #17: Improved rating of intonation by speech-language pathology blinded graduate students.

OUTCOME #18: Improved rating of articulatory precision by speech-language pathology blinded graduate students.

OUTCOME #19: Improved intelligibility as represented by the percentage of intelligible words (PIW) in words

OUTCOME #20: Improved intelligibility as represented by the ease of understanding (EI) as measured on a 1 (easy) to 5 (difficult scale)

OUTCOME #21: Increased PIW to EI ratio (PIW/EI)

OUTCOME #22: Improved rating on the Minnesota Improved Satisfactoriness Scales by the participant’s (P) supervisor in her volunteer position

OUTCOME #23: Improved self-perception of P of her communication,                                        

  • The following outcomes are objective:

OUTCOME #1: Improved sound pressure level (SPL) in sustained vowels

OUTCOME #2: Improved SPL in the Rainbow Passage

OUTCOME #3: Improved SPL in the description of a picture

OUTCOME #4: Improved SPL in a monologue

OUTCOME #5: Improved SPL in specific sentences

OUTCOME #6: Improved mean fundamental frequency (Fo) for the Rainbow Passage

OUTCOME #7: Improved mean Fo in the description of a picture

OUTCOME #8: Improved mean Fo in a monologue

 

OUTCOME #9: Improved mean Fo for specific sentences

OUTCOME #10: Improved Fo standard deviation (SD) for the Rainbow Passage in semitones (STSD)

OUTCOME #11: Improved STSD in the description of a picture

OUTCOME #12: Improved STSD in a monologue

OUTCOME #13: Improved STSD for specific sentences

OUTCOME #14: Increased overall vowel formant triangle

OUTCOME #15: Increased overall vowel formant dynamics (i.e., increased formant frequency SD from their means

OUTCOME #16: Increased vowel formant triangle of specific vowels

OUTCOME #24: Decreased rate of speech

                                                       

  • The following outcome measures were associated with reliability data:

– Combined reliability measures for Outcomes #6-9:

OUTCOME #6: Improved mean fundamental frequency (Fo) for the Rainbow Passage

OUTCOME #7: Improved mean Fo in the description of a picture

OUTCOME #8: Improved mean Fo in a monologue

OUTCOME #9: Improved mean Fo for specific sentences

  • Overall intrarater reliability:

– Standard Error of Measurement (SEM) = 2.05 Hz

– Correlation: r = 1.0

  • Overall interater reliability:

– Standard Error of Measurement (SEM) = 4.17 Hz

– Correlation: r = 1.0

 

-Combined reliability measures for Outcomes #10-13:

OUTCOME #10: Improved Fo standard deviation (SD) for the Rainbow Passage in semitones (STSD)

OUTCOME #11: Improved STSD in the description of a picture

OUTCOME #12: Improved STSD in a monologue

OUTCOME #13: Improved STSD for specific sentences

  • Overall intrarater reliability:

– Standard Error of Measurement (SEM) = 0.12 semitones

– Correlation: r = 0.99

  • Overall interater reliability:

– Standard Error of Measurement (SEM) = 0.27 semitones

– Correlation: r = 0.97

– Combined reliability measures for Outcomes #14-16:

OUTCOME #14: Increased overall vowel formant triangle

OUTCOME #15: Increased overall vowel formant dynamics (i.e., increased formant frequency SD from their means

OUTCOME #16: Increased vowel formant triangle of specific vowels

  • Overall intrarater reliability:

– Standard Error of Measurement (SEM)

     for mean F1 = 23.7 Hz

     for SD F1 = 16.08 Hz

     for mean F2 = 38.38 Hz

     for SD F2 = 38.17 Hz

– Correlation:

     for mean F1: r = 0.88

     for SD F1: r = 0.89

     for mean F2: r = 0.93

     for SD F2: r = 0.95

  • Overall interater reliability:

– Standard Error of Measurement (SEM)

     for mean F1 = 41.11 Hz

     for SD F1 = 22.45 Hz

     for mean F2 = 52.75 Hz

     for SD F2 = 60.08 Hz

– Correlation:

     for mean F1: r = 0.81

     for SD F1: r = 0.88

     for mean F2: r = 0.90

     for SD F2: r = 0.82

OUTCOME #17: Improved rating of intonation by speech-language pathology blinded graduate students.

  • Intrarater reliability:   96% agreement
  • Interrater reliability: 98% agreement

– OUTCOME #18: Improved rating of articulatory precision by speech-language pathology blinded graduate students.

  • Intrarater reliability: 71% agreement
  • Interrater reliability: 80% agreement  

OUTCOME #24: Decreased rate of speech

  • Interrater reliability: r = 0.77

 

  1. Results:
  • Did the target behavior improve when it was treated? Yes
  • The overall quality of improvement for each of the outcomes was

OUTCOME #1: Improved sound pressure level (SPL) in sustained vowels – large improvement

OUTCOME #2: Improved SPL in the Rainbow Passage – large improvement

OUTCOME #3: Improved SPL in the description of a picture – large improvement

OUTCOME #4: Improved SPL in a monologue – large improvement

OUTCOME #5: Improved SPL in specific sentences – large improvement

OUTCOME #6: Improved mean fundamental frequency (Fo) for the Rainbow Passage – large improvement

OUTCOME #7: Improved mean Fo in the description of a picture– large improvement

OUTCOME #8: Improved mean Fo in a monologue – large improvement

OUTCOME #9: Improved mean Fo in specific sentences – large improvement

OUTCOME #10: Improved Fo standard deviation (SD) for the Rainbow Passage in semitones (STSD) – large improvement

OUTCOME #11: Improved STSD in the description of a picture – large improvement

OUTCOME #12: Improved STSD in a monologue – large improvement

OUTCOME #13: Improved STSD for specific sentences – large improvement

OUTCOME #14: Increased overall vowel formant triangle  — moderate increase in size of vowel triangle

OUTCOME #15: Increased overall vowel formant dynamics (i.e., increased formant frequency SD from their means–large improvement for 2 of 3 sentences for F1; F2 yielded large improvement for all sentences

OUTCOME #16: Increased vowel formant triangle of specific vowels — moderate increase in size of vowel triangle

OUTCOME #17: Improved rating of intonation by speech-language pathology blinded graduate students—moderate improvement and statistically significant

OUTCOME #18: Improved rating of articulatory precision by speech-language pathology blinded graduate students — moderate improvement

OUTCOME #19: Improved intelligibility as represented by the percentage of intelligible words (PIW) in words —small improvement

OUTCOME #20: Improved intelligibility as represented by the ease of understanding (EI) as measured on a 1 (easy) to 5 (difficult scale) —small improvement

OUTCOME #21: Increased PIW to EI ratio (PIW/EI) —small improvement but   statistically significant (t-test)

OUTCOME #22: Improved rating on the Minnesota Improved Satisfactoriness Scales by the participant’s (P) supervisor in her volunteer position—moderate improvement

OUTCOME #23: Improved self-perception of P of her communication, socialization, and work skills. Moderate improvement

OUTCOME #24: Decreased rate of speech—moderate improvement

  1. Description of baseline:

 

  • Were baseline data provided? Yes

The number of data points for each dependent variable/outcome were

 

Acoustic Measures (Outcomes #1 to #16 and #24): 3 baseline sessions

– Perceptual Measures (Outcome#17 to #21): 1 pretest/baseline session

– Social Measures (Outcomes #22 and #23): 1 pretest/baseline session

 

  • Was baseline low and stable?

– Data were only provided for Outcomes #1 to #5; in all cases baseline was low/moderate and stable

                                                       

  • What was the percentage of nonoverlapping data (PND)? Insufficient data. This was a case study.

 

 

  1. What was the magnitude of the treatment effect?

 

  • The investigators identified the following outcomes as having a large effect using pre and post testing score. The criterion of “large effect” was 1 SD improvement or better. The outcomes that are not listed were not accompanied by the EBP data.

OUTCOME #1: Improved sound pressure level (SPL) in sustained vowels

OUTCOME #2: Improved SPL in the Rainbow Passage

OUTCOME #3: Improved SPL in the description of a picture

OUTCOME #4: Improved SPL in a monologue

OUTCOME #5: Improved SPL in specific sentences

OUTCOME #6: Improved mean fundamental frequency (Fo) for the Rainbow Passage

OUTCOME #7: Improved mean Fo in the description of a picture

OUTCOME #8: Improved mean Fo in a monologue

OUTCOME #9: Improved mean Fo for specific sentences

OUTCOME #10: Improved Fo standard deviation (SD) for the Rainbow Passage in semitones (STSD)

OUTCOME #11: Improved STSD in the description of a picture

OUTCOME #12: Improved STSD in a monologue

OUTCOME #13: Improved STSD for specific sentences

OUTCOME #14: Increased overall vowel formant triangle (

OUTCOME #22: Improved rating on the Minnesota Improved Satisfactoriness Scales by the participant’s (P) supervisor in her volunteer position

 

  1. Was information about treatment fidelity adequate? Not Provided

 

 

  1. Were maintenance data reported? Yes
  • Most of the outcomes were assessed 9 months after the ending of treatment. All of the outcomes that were administered follow-up testing maintained progress. There were, however, Social Outcomes (Outcomes #22 and #23) for which no follow up testing were administered.

 

 

  1. Were generalization data reported? Yes, with the exception of Outcome # 1, that was concerned with the vocalization of ‘ah,’ none of the outcomes appeared to involve trained behaviors. Therefore, generalization from treatment to other context occurred.

 

 

  1. Brief description of the design:

 

  • This case study involved pretesting and post testing on numerous measures tapping acoustic, perceptual, and social outcomes.
  • Most of the measures were obtained in multiple sessions (3 pretest session, 2 post test sessions)
  • For most of the outcomes, the investigators collected follow-up measures, 9 months after the termination of therapy.
  • The investigators described procedures for measuring the acoustic outcomes and for insuring reliability of perceptual judgments.

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

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of LSVT.

POPULATION: ataxic dysarthria; adult

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, pitch, intonation, rate

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness, pitch

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: articulation (precision, vowel), intelligibility

 

OTHER TARGETS: perception of social functioning

DOSAGE: 16 sessions over 4 weeks, individual sessions

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

  • The focus of intervention was to produce maximum loudness while maintaining healthy use of the vocal mechanism.
  • Techniques included identification and practice of optimal phonation and loudness using all aspects of the phonatory system, self-monitoring, and carry-over activities (generalization to activities of daily living.)
  • Sessions included activities focusing sustained phonation of vowels such as “ah,” producing highest and lowest possible Fo while maintaining a healthy voice quality, producing connected speech while maintaining the loudest possible phonation with a healthy voice quality.
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