Lee & Son (2005)

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

GRBAS Scale = Grade, Rough, Breathiness, Asthenic, Strained Scale

MTD = muscle tension dysphonia

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SFo = speaking fundamental frequency

SLP = speech–language pathologist

 

 

SOURCE: Lee, E-K, & Son, Y-I. (2005). Muscle tension dysphonia in children: Voice characteristics and outcome of voice therapy. International Journal of Pediatric Otorhinolaryngology, 69, 911-917. doi: 10.1016/j.ijporl.2005.01.030

 

REVIEWER(S): pmh

 

DATE: December 5, 2015

 

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

 

TAKE AWAY: Korean speaking children with muscle tension dysphonia (MTD) received therapy targeting awareness, relaxation, breathing, phonation, and homework. The results of this retrospective, descriptive, single group investigation revealed that children with a diagnosis of MTD are amenable to intervention and that marked progress was noted in voice quality and pitch as well as in reducing hypercontraction.

 

 

  1. What type of evidence was identified?

                                                                                                           

– What was the type of evidence? Retrospective, 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.
  • If there were groups and Ps were not randomly assigned to groups, were members of groups carefully matched? NA

                                                                    

 

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

                                                                    

 

  1. Was the group adequately described? Yes

 

– How many Ps were involved in the study?

 

  • total # of Ps: 8; records were examined for 8 consecutive male children with MTD
  • # of groups: 1

 

– The P characteristics that were controlled (i.e., inclusion/exclusion criteria) included

  • age: children
  • gender: all male

 

– The P characteristics were described included

  • age: 4.2 to 12.2 years, mean = 7.5 years
  • Onset: 4 months previous to several years (see Table 1)
  • Previous intervention: no previous voice therapy; no previous medication for the voice symptoms
  • Associated medical findings: vocal nodules (7 participants, P); post upper respiratory infection (2Ps)
  • Comorbid communication problems: articulation disorder (1P); dysfluency (1P)

 

– Were the groups similar before intervention began? NA

                                                         

– Were the communication problems adequately described? Yes

  • disorder type: voice problem, MTD
  • functional level: A speech-language pathologist (SLP) perceptually rated Ps using the Grade, Rough, Breathiness, Asthenic, Strained (GRBAS) Scale. The following voice problems were noted:

– severe hoarseness – all Ps

– strained voice – all Ps

– breathiness – all Ps to varying degrees

– pitch problems – 6 Ps (e.g., diplophonia, high/low pitch, pitch breaks)

– phonation breaks – 2 Ps

– aphonia – 2 Ps

  • other

– vocal nodules—7Ps

– false vocal fold approximation

– decreased vibration of true vocal folds

– incomplete glottal closure

 

 

  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, but some data were lost due to technical or procedural issues.

 

 

  1. Were the groups controlled acceptably? NA

                                                                                                             

 

  1. Were the outcomes measure appropriate and meaningful? Yes

                                                                                                             

– The outcomes (dependent variables) were

 

PERCEPTUAL OUTCOMES

  • OUTCOME #1: Improved performance on the Grade portion of the GRBAS scale
  • OUTCOME #2: Improved performance on the Rough portion of the GRBAS scale
  • OUTCOME #3: Improved performance on the Breathiness portion of the GRBAS scale
  • OUTCOME #4: Improved performance on the Asthenic portion of the GRBAS scale
  • OUTCOME #5: Improved performance on the Strained portion of the GRBAS scale

 

ACOUSTIC OUTCOMES

  • OUTCOME #6: Improved speaking fundamental frequency (SFo)
  • OUTCOME #7: Reduced rate of jitter
  • OUTCOME #8: Reduced rate of shimmer
  • OUTCOME #9: Reduced noise to harmonic ratio (NHR)

 

STROBOSCOPIC OUTCOME

  • OUTCOME #10: Improved vocal fold function/status

 

– The subjective outcome measures were

 

PERCEPTUAL OUTCOMES

  • OUTCOME #1: Improved performance on the Grade portion of the GRBAS scale
  • OUTCOME #2: Improved performance on the Rough portion of the GRBAS scale
  • OUTCOME #3: Improved performance on the Breathiness portion of the GRBAS scale
  • OUTCOME #4: Improved performance on the Asthenic portion of the GRBAS scale
  • OUTCOME #5: Improved performance on the Strained portion of the GRBAS scale

 

STROBOSCOPIC OUTCOME

  • OUTCOME #10: Improved vocal fold function/status

 

The objective outcome measures were

 

ACOUSTIC OUTCOMES

  • OUTCOME #6: Improved speaking fundamental frequency (SFo)
  • OUTCOME #7: Reduced rate of jitter
  • OUTCOME #8: Reduced rate of shimmer
  • OUTCOME #9: Reduced noise to harmonic ratio (NHR)

                                         

 

  1. Were reliability measures provided?
  • Interobserver for analyzers? No
  • Intraobserver for analyzers? No
  • Treatment fidelity for clinicians? No

 

 

  1. What were the descriptive results (i.e., there was no statistical analysis)?

 

– Summary Of Important Results

 

 

PRE AND POST TREATMENT ONLY ANALYSES

 

PERCEPTUAL OUTCOMES—Descriptive Results Only

  • OUTCOME #1: Improved performance on the Grade portion of the GRBAS scale – Marked improvement noted
  • OUTCOME #2: Improved performance on the Rough portion of the GRBAS scale—Improvement noted
  • OUTCOME #3: Improved performance on the Breathiness portion of the GRBAS scale—Improvement noted
  • OUTCOME #4: Improved performance on the Asthenic portion of the GRBAS scale—Improvement noted
  • OUTCOME #5: Improved performance on the Strained portion of the GRBAS scale– Marked improvement noted

 

ACOUSTIC OUTCOMES—Descriptive Results Only

  • OUTCOME #6: Improved speaking fundamental frequency (SFo) — Low or high pitch returned to normal range; P using 2 pitches converted to a single stable pitch.
  • OUTCOME #7: Reduced rate of jitter—6Ps of the 7Ps with complete data reduced rate of jitter; investigators described jitter as being stabilized
  • OUTCOME #8: Reduced rate of shimmer–5Ps of the 7Ps with complete data reduced rate of shimmer; investigators described shimmer as being stabilized
  • OUTCOME #9: Reduced noise to harmonic ratio (NHR)– 6P of the 7Ps with complete data reduced rate of shimmer; investigators described NHR as being stabilized

 

STROBOSCOPIC OUTCOME—Descriptive Results Only

  • OUTCOME #10: Improved vocal fold function/status —4P of the 4Ps with complete data presented with improved vocal fold function/status; investigators described reduced anterioposterior contraction and reduction in nodule siz2

 

– What was the statistical test used to determine significance? NA, there were no statistical analyses

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significanceNA, no measures of clinical significance were reported.

 

 

  1. Were maintenance data reported? Yes
  • The investigators contacted the parents of 5 the Ps 2 ½ years after the completion of the intervention via the phone.
  • The parents reported that

– voice quality continued to be unstrained (5Ps)

– no abnormally high or low SFo (5Ps)

– no pitch or phonation breaks (5Ps)

– breathy voice quality continued to be reduced (4Ps)

– multiple voice abuse episodes (1P)

 

 

  1. Were generalization data reported? Yes. The investigators focused part of treatment on carrying over what was learned in therapy to outside the clinic. Therefore, the maintenance data (item #11) could also be considered generalization data.

 

 

  1. Describe briefly the experimental design of the investigation.
  • Investigators reviewed files until they identified 8 consecutive Korean speaking children who had been diagnosed with MTD, received intervention, and had been assessed pre and post intervention with a battery of perceptual, acoustic, and stroboscopic measures.
  • The intervention targeted awareness, relaxation, breathing, and phonation as well as assigned homework.
  • The investigators interviewed by phone the parents of 5Ps 2 ½ years after the end of intervention to assess maintenance.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C-

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of an intervention for MTD in children.

 

POPULATION: Muscle tension dystonia (MTD), Voice problems; Children

 

MODALITY TARGETED: expressive

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: pitch

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: voice quality (hoarseness, roughness, aphonia, diplophonia, etc.)

 

DOSAGE: 1 or 2 times a week, 30 minute sessions, for 1 to 2 ½ months

 

ADMINISTRATOR: SLP with homework by family

 

MAJOR COMPONENTS:

 

  • Intervention involved targeting awareness, relaxation, breathing, phonation, and encouraging family involvement at home (homework)

 

  • AWARENESS:

– The clinician (C) worked with the P and his family to develop an awareness of his voice problem(s) by reviewing recordings of the P’s speech.

– C worked with P so that he was able to identify voice problems on recordings.

– C described vocal abuse and good vocal hygiene.

 

  • RELAXATION:

– C described excessive muscle tension and provided visual and kinesthetic feedback to the P.

– C provided manual circumlaryngeal massage to the P.

 

  • BREATHING:

– C provided respiration training.

 

  • PHONATION:

– C directed P to hum and then feel the vibrations in his nose and neck.

– C instructed P to practice vocalizing vowels preceded by /h/ by

  • sighing,
  • producing the vowel, and
  • noting the easy-onset of the /h/ as opposed to his habitual harsh onset.

– C gradually increased the length and complexity of utterances.

– C encouraged P to self-monitor.

– C engaged P in role playing.

 

  • HOMEWORK:

– C encouraged family members to attend sessions.

– C asked family members to monitor P’s behavior and to complete homework assignments.

– The homework assignments included practicing skills used in therapy to communication outside the clinic.

 

 

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