Martens et al. (2015)

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

f = female

Fo-max last syllable = maximum fundamental frequency of the last syllable (Fo-max last syllable)

Fo-max median= median maximum fundamental frequency

m = male

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

SPRINT therapy = speech rate and intonation therapy

 

 

SOURCE: Martens, H., Van Nuffelen, G., Dekens, T., Hernández-Díaz Huicia, M., Arturo Kairuz Hernández-Díaz, M., De Letter, M., &, De Bodt, M. (2015). The effect of intensive speech rate and intonation therapy of intelligibility of Parkinson’s disease. Journal of Communication Disorders, 58, 91 -105.

 

 

REVIEWER(S): pmh

 

DATE: November 23, 2015

 

ASSIGNED GRADE FOR OVERALL QUALITY: C+ (The highest possible grade based on the design was C+.)

 

TAKE AWAY: Eleven Dutch speakers diagnosed with hypokinetic dysarthria due to Parkinson’s disease received an intensive course of speech therapy focusing on rate and intonation to improve intelligibility. Intelligibility improved significantly with a large effect size. Several other measures also improved including measures associated with the perception of intonation representing questions or statements, the frequency of pauses, and maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in reading and repetition tasks.

 

 

  1. What type of evidence was identified?

                                                                                                           

– What was the type of evidence? Prospective, Single Group with Pre- and Post-Testing  

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

 

                                                                                                           

  1. Group membership determination:
  • If there was more than one group, were participants (Ps) randomly assigned to groups? Not Applicable (NA), there was only one group.

 

  1. Was administration of intervention status concealed?
  • from participants? No
  • from clinicians? No
  • from analyzers? Unclear

                                                                    

 

  1. Were the groups adequately described? Yes

 

How many Ps were involved in the study?

  • total # of Ps: 11 (from a volunteer group of 42)
  • # of groups: 1

 

The P characteristics that were controlled included

  • age:
  • gender:
  • diagnosis: idiopathic Parkinson’s disease (PD)
  • neurological status: no comorbid neurological disorders
  • motivation: following screening interview still indicated he/she was willing to participate in rigorous intervention
  • vision: determined to be sufficient during screening interview
  • hearing: determined to be sufficient during screening interview
  • cognitive skills: determined to be sufficient during screening interview
  • language: determined to be sufficient during screening interview
  • reading: determined to be sufficient during screening interview
  • intelligibility: reduced intelligibility on the Dutch Sentence Intelligibility Assessment (<90% intelligible)        
  • receptive prosody skills: score ≥ 80% on test, if necessary after a 1 hour receptive prosody training session

 

The P characteristics that were described included

  • age: 52 to 94 years; mean 70 years
  • gender: 7m; 4f
  • anti PD medication: All Ps were receiving anti PD medications; the specific medications for each P is listed in Table 1.  
  • received Deep Brain Stimulation: 4 yes; 7 no
  • previous speech therapy: 5 Ps had a history of speech therapy for loudness and/or rate
  • current speech therapy: suspended during the intervention
  • years since diagnosis: 4 to 29 years; mean 16 years
  • language spoken: Dutch

 

Were the groups similar before intervention began? NA

                                                         

–  Were the communication problems adequately described? Yes

  • disorder type: hypokinetic dysarthria
  • functional level:

     – severity of dysarthria ranged from mild (2 Ps) to moderate (8 Ps) with 1 P undermined

– sentence intelligibility ranged from 64% to 90%

 

 

  1. Was membership in groups maintained throughout the study?

Did the group maintain at least 80% of their original members? Yes

Were data from outliers removed from the study? No

 

 

  1. Were the groups controlled acceptably? NA

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

–   The outcomes (dependent variables) were

 

PERCEPTUAL MEAURES:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences
  • OUTCOME #2: Improved intonation of questions and statements in reading and repetition
  • OUTCOME #3: Improved intonation of questions in reading and repetition
  • OUTCOME #4: Improved intonation of statements in reading and repetition
  • OUTCOME #5: Improved intonation of questions and statements in reading
  • OUTCOME #6: Improved intonation of questions and statements in repetitions

 

AUTOMATED MEASURES:

  • OUTCOME #7: Improved speech rate (number of syllables per second including pauses) in a read passage
  • OUTCOME #8: Improved speech rate (number of syllables per second including pauses) in story telling
  • OUTCOME #9: Improved speech rate (number of syllables per second including pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #10: Improved articulation rate (number of syllables per second excluding pauses) in a read passage
  • OUTCOME #11: Improved articulation rate (number of syllables per second excluding pauses) in story telling
  • OUTCOME #12: Improved articulation rate (number of syllables per second excluding pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #13: Increased mean pause time in read passages
  • OUTCOME #14: Increased mean pause time in story telling
  • OUTCOME #15: Increased mean pause time during the intelligibility test—read nonsense test
  • OUTCOME #16: Increased mean number of pauses in read passages
  • OUTCOME #17: Increased mean number of pauses in story telling
  • OUTCOME #18: Increased mean number of pauses during the intelligibility test—read nonsense test

 

ACOUSTIC MEASURES:

  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence repetition task
  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence repetition task
  • OUTCOME #21: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence reading task  
  • OUTCOME #22: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence repetition task  
  • OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task  
  • OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task  

 

– The outcome measures that are subjective are

 

PERCEPTUAL MEAURES:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences
  • OUTCOME #2: Improved intonation of questions and statements in reading and repetition
  • OUTCOME #3: Improved intonation of questions in reading and repetition
  • OUTCOME #4: Improved intonation of statements in reading and repetition
  • OUTCOME #5: Improved intonation of questions and statements in reading
  • OUTCOME #6: Improved intonation of questions and statements in repetitions

 

 

– The objective outcome measures are

 

AUTOMATED MEASURES:

  • OUTCOME #7: Improved speech rate (number of syllables per second including pauses) in a read passage
  • OUTCOME #8: Improved speech rate (number of syllables per second including pauses) in story telling
  • OUTCOME #9: Improved speech rate (number of syllables per second including pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #10: Improved articulation rate (number of syllables per second excluding pauses) in a read passage
  • OUTCOME #11: Improved articulation rate (number of syllables per second excluding pauses) in story telling
  • OUTCOME #12: Improved articulation rate (number of syllables per second excluding pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #13: Increased mean pause time in read passages
  • OUTCOME #14: Increased mean pause time in story telling
  • OUTCOME #15: Increased mean pause time during the intelligibility test—read nonsense test
  • OUTCOME #16: Increased mean number of pauses in read passages
  • OUTCOME #17: Increased mean number of pauses in story telling
  • OUTCOME #18: Increased mean number of pauses during the intelligibility test—read nonsense test

 

ACOUSTIC MEASURES:

  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence repetition task
  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence repetition task
  • OUTCOME #21: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence reading task  
  • OUTCOME #22: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence repetition task  
  • OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task  
  • OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task  

 

                                         

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Yes

  • Combined reliability for Perceptual Measures (Outcomes #1 through #6 which are listed below the reliability data) was high:

– Pre-treatment Intraclass Correlation Coefficient = 0.831

– Post-treatment Intraclass Correlation Coefficient = 0.933

OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences

OUTCOME #2: Improved intonation of questions and statements in reading and repetition

OUTCOME #3: Improved intonation of questions in reading and repetition

OUTCOME #4: Improved intonation of statements in reading and repetition

OUTCOME #5: Improved intonation of questions and statements in reading

OUTCOME #6: Improved intonation of questions and statements in repetitions

 

– Intraobserver for analyzers? Yes

  • Combined reliability for Perceptual Measures (Outcomes #1 through #6 which are listed below the reliability data) was high:

– Pre-treatment Intraclass Correlation Coefficient = 0.935

– Post-treatment Intraclass Correlation Coefficient = 0.799

OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences

OUTCOME #2: Improved intonation of questions and statements in reading and repetition

OUTCOME #3: Improved intonation of questions in reading and repetition

OUTCOME #4: Improved intonation of statements in reading and repetition

OUTCOME #5: Improved intonation of questions and statements in reading

OUTCOME #6: Improved intonation of questions and statements in repetitions

 

  • Reliability for Fo max which was used for Measures/ Outcomes #19 through #24 (they are listed below the reliability data ) was high:

– Pre-treatment Intraclass Correlation Coefficient = 0.998

– Post-treatment Intraclass Correlation Coefficient = 0.997

OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence reading task

OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence repetition task

OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence reading task

OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence repetition task

OUTCOME #21: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence reading task  

OUTCOME #22: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence repetition task  

OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task  

OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task  

 

– Treatment fidelity for clinicians? Yes

  • Clinicians (C), 4 master’s graduate students in speech-language pathology, followed a treatment protocol.
  • The first author supervised the Cs.

 

 

  1. What were the results of the statistical (inferential) testing?

 

SUMMARY OF IMPORTANT RESULTS

 

— What level of significance was required to claim significance? p = 0.05

 

PRE AND POST TREATMENT ONLY ANALYSES

(only the Outcomes that achieved significance are listed)

 

PERCEPTUAL MEASURES:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences – postintervention was significantly higher than preintervention
  • OUTCOME #2: Improved intonation of questions and statements in reading and repetition–postintervention was significantly better than preintervention
  • OUTCOME #3: Improved intonation of questions in reading and repetition – postintervention was significantly better than preintervention
  • OUTCOME #5: Improved intonation of questions and statements in reading – postintervention was significantly better than preintervention

 

AUTOMATED MEASURES:

  • OUTCOME #16: Increased mean number of pauses in read passages – postintervention was significantly larger than preintervention

 

ACOUSTIC MEASURES:

  • OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task – postintervention was significantly higher than preintervention
  • OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task – postintervention was significantly higher than preintervention

 

– What was the statistical test used to determine significance? Wilcoxon

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance

– What measure was used? Nonparametric Effect Size

 

– Results of EBP testing and the interpretation:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences—nonparametric effect sixe = 0.83 (large effect)

 

 

  1. Were maintenance data reported? No

If yes, summarize findings:

 

  1. Were generalization data reported?  Yes
  • Since intelligibility was not the focus of the intervention, the outcome associated with intelligibility can be considered to be generalization.
  • The investigators reported that the post-intervention intelligibility was significantly higher than pre-invention intelligibility and that the effect size was large.

 

  1. Describe briefly the experimental design of the investigation.
  • In this single group, pre/post test investigation, 11 Ps from a volunteer group of 42 volunteers were selected using inclusion/exclusion criteria.
  • The Ps were all exposed to the same treatment administered by Cs who were master’s students in speech-language pathology. They were supervised by the first author.
  • The Ps were tested no more than 3 weeks before the intervention (pre) and no more than 3 days after treatment (post.)
  • The Cs administered the intervention over 3 weeks targeting speech rate and intonation.

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C+

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of an intensive intervention for PD using speech rate and intonation to improve intelligibility.

 

POPULATION: Parkinson’s disease, hypokinetic dysarthria

 

MODALITY TARGETED: expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: rate, intonation (terminal contour, overall)

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rate, intonation (terminal contour)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: intelligibility

 

DOSAGE: 5 one-hour individual sessions per week for 3 weeks

 

ADMINISTRATOR: master’s students in speech-language pathology

 

STIMULI: auditory, rhythmic gestures (hand tapping)

 

MAJOR COMPONENTS:

 

  • Intervention included the use of the Prosodietrainer, software developed for Dutch speakers with dysarthria. The Prosodietrainer records the Ps’ verbalizations, allows the P to replay his/her attempts, and provides visual feedback. However, the visual feedback monitor was not used in this investigation because it was in an experimental phase and because there was concern that Ps might be distracted by it.

 

  • During the initial sessions, the Cs explained that rate and intonation interventions were being implemented to improve intelligibility. The Cs did not directly target intelligibility during the intervention.

 

  • Intervention was intense—5 one-hour sessions per week for 3 weeks (15 sessions.)

 

  • Cs followed a protocol that specified

– intervention dosage

– content

– hierarchy of intervention steps

– feedback strategies

 

  • Major focus:

– reduce speaking rate (during the 1st half hour of a session)

– increase the contrast of the phrase final syllable of questions and statements (during the 2nd half hour of a session)

 

  • Rate reduction procedures:

– C instructed P to reduce rate by half.

– If the instruction was not successful, C used modeling or hand tapping to reduce rate.

– C did not instruct P to increase sound length or pause length.

 

  • Final syllable contrasts for statements versus questions:

– C directed P to

– produce questions with a rising terminal contour

– produce statements with a falling terminal contour

  • C provided feedback to P regarding the accuracy of attempts.

 

  • The intervention hierarchy involved increasing the linguistic complexity, length, and task complexity of the targets. The Prosodietrainer was programmed to individualize targets based on the Ps’ skill levels.

 

  • The Cs adhered to the principles of motor learning by providing clear brief instructions and models.

 

  • SPRINT therapy also involves massed practice.

 

  • Cs provided feedback regarding P performance and the functional accuracy of productions. As intervention progress, Cs gradually increased the rate and the delay time of feedback.
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