Zumbasen et al. (2014)

EBP THERAPY ANALYSIS for

Single Subject Designs

 

 

 

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

 

Key:

C = Clinician

CIU = Correct Information Units

EBP = evidence-based practice

f = female

m = male

MT = melodic therapy, the adaptation of MIT used in this investigation that used pitch and rhythm

MIT = Melodic Intonation Therapy

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

RT = rhythmic therapy, the adaptation of MIT used in this investigation that used rhythm

SLP = speech–language pathologist

ST = spoken therapy, the adaptation of MIT used in this investigation that was spoken

 

 

SOURCE: Zumbansen, A., Peretz, I., & Herbert, S. (2014). The combination of rhythm and pitch can account for the beneficial effect of melodic intonation therapy on connected speech improvements in Broca’s aphasia. Frontiers in Human Neuroscience, 8, 592. doi: 10.3389/fnhum.2014.00592

 

REVIEWER(S): pmh

 

DATE: March 16, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: A- (The highest possible grade based on the design of the investigation was A-.)

 

TAKE AWAY: The investigators in these single subject studies explored the relative contribution of rhythm and pitch to the effectiveness of Melodic Intonation Therapy (MIT) for French speaking patients (Ps) with Broca’s Aphasia (MT.) MT yielded significantly better outcomes of discourse informativeness than MIT adaptations using rhythm only (RT) or spoken words only (ST.) All 3 adaptations of MIT (MT, RT, ST) resulted in significant improvements in the imitation of trained words but improvement with untrained words was consistently better with MT than RT or ST. None of the interventions resulted in improved measures of diadochokinetic rate or of mood.

 

 

  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? Single Subject Experimental Design with Specific Clients-– Latin Square Cross-Over

                                                                                                           

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

 

 

  1. Was phase of treatment concealed?
  • from participants? No
  • from clinicians? No
  • from analyzers? Unclear. For data derived from verbal performances, analysts were not the same person as the clinician (C) but it is not clear the analysts were blinded regarding the intervention status of the Ps.

                                                                                                           

 

  1. Were the groups adequately described? Yes

 

– How many Ps were involved in the study?

– total # of Ps:   3

– # of groups: 1

– List names of groups and the # of participants in each group:

  • The names of the Ps were
  • FL
  • FS
  • JPL

 

– The P characteristics were CONTROLLED included

  • time since onset: at least one year
  • diagnosis: Broca’s Aphasia

 

– The P characteristics that were DESCRIBED included

  • age: 48 – 57 years
  • gender: All Ps were male.
  • cognitive skills: All Ps were within normal limits for nonverbal intelligence
  • memory: All Ps were within normal limits
  • receptive language:
  • handedness: right
  • language spoken: French
  • residence: Greater Montreal area
  • etiology: “single ischemic unilateral left hemisphere cerebrovascular accident” (p. 3)
  • time since onset: at least one year
  • previous therapy: all had been involved in “standard rehabilitation services” (p. 3) including being terminated from speech-language therapy when they reached a plateau.
  • pre-existing comorbid neurological or psychiatric problems: None
  • executive functioning: All Ps were within normal limits
  • visual skills: All Ps were within normal limits on a test of visual agnosia
  • hearing acuity: All within normal limits
  • comorbid physical problems:

– right upper limb hemiplegia 2 Ps continued to experience this; 1 P had almost recovered from it

  • musical abilities: 2 Ps were within normal limits; 1 P was below the cut-off for 2 of 3 subtests
  • years of formal music education: None of the Ps had any formal music education
  • comorbid social emotional status: 1 P experienced depression
  • comorbid neurological problems: All Ps had experienced focal epilepsy
  • educational level of Ps: 13 – 17 years

                                                         

– Were the communication problems adequately described? Yes

 

  • disorder type: (List) Broca’s Aphasia (All Ps displayed problems with naming, grammar, apraxia but had moderately preserved comprehension of simple communication)
  • functional level

     – severity of Broca’s Aphasia: moderate (2Ps); severe, including more severe apraxia (1P)

  • other
  • candidacy for Melodic Intonation Therapy (MIT): All 3 met standards for involvement in MIT
  • performance on language tests:

– Language Expression: All Ps were not functioning within normal limits.

– Naming: All Ps were not functioning within normal limits.

         – Narrative Discourse: All Ps were not functioning within normal limits.

– Fluency: Ps’ performances ranged from moderately to severely impaired.

– Agrammatism: All Ps’ performances were severely impaired.

– Syntactic deviations: Ps’ performances ranged from moderately to severely impaired.

         – Anomia: Ps’ performances ranged from moderately to severely impaired.

         – Phonetic deviations: Ps’ performances ranged from moderately to severely impaired.

         – Phonemic deviations: Ps performances ranged from moderately to severely impaired.

– Semantic deviations: Ps performances ranged from mildly to moderately impaired.

          – Repetition: All Ps were not functioning within normal limits.

– Overall Comprehension: All Ps were not functioning within normal limits.

– Word Comprehension: All Ps were functioning within normal limits.

– Sentence Comprehension: All Ps were not functioning within normal limits.

 

 

  1. Was membership in treatment maintained throughout the study?                                Yes ___x__       No _____     Unclear ____   Not applicable _____

 

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

 

 

  1. Did the design include appropriate controls?

Yes __x___           No _____         Unclear ____   Varied _____

                                                                      

  • Were preintervention data collected on all behaviors? Yes

 

  • Did intervention data include untrained stimuli? Yes

 

  • Did intervention data include trained stimuli? Yes

 

  • Was the data collection continuous? No

 

  • Were different treatment counterbalanced or randomized? Yes

 

  • If answer to the above was yes, describe the control: Randomized

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

– The outcomes were

 

  • OUTCOME #1: Increased discourse informativeness as measured in Correct Information Units (CIU)

 

  • OUTCOME #2: Increase number of correct sentences in the repetition of trained and untrained sentences
  • OUTCOME #3: Increased diadochokinetic rate (to measure changes in apraxia of speech)
  • OUTCOME #4: Improved mood as measures using a visual analog procedure

 

All the outcome measures were subjective.

 

– None of the outcome measures were objective.

 

  1. Results:

 

Did the target behaviors improve when treated? Variable

 

  • OUTCOME #1: Increased discourse informativeness as measured in Correct Information Units (CIU)

     – FL:   significant progress only with the melodic adaptation of MIT (MT)

     – FS:   significant progress only with MT

     – JPL: significant progress only with MT

  • OUTCOME #2: Increase number of correct sentences in the repetition of trained and untrained sentences

     – FL:

  • trained sentences: significant improvement in all treatments
  • untrained sentences:

significant improvement in MT only but

               – the improvement in trained versus untrained sentence following MT was not significantly different

 

     – FS:  

  • trained sentences:

significant improvement in all treatments but

               – trained sentences improved significantly more than untrained sentence on RT and ST but not MT

  • untrained sentences: significant improvement in all treatments

 

     – JPL:

  • trained sentences:

significant improvement in all treatments but

               – trained sentences improved significantly more than untrained sentence on RT but not MT

  • untrained sentences: significant improvement following MT and RT but not ST
  • OUTCOME #3: Increased diadochokinetic rate (to measure changes in apraxia of speech)

     – FL: no significant differences

     – FS: no significant differences

     – JPL: no significant differences

 

  • OUTCOME #4: Improved mood as measures using a visual analog procedure

     – FL: no significant differences

     – FS: no significant differences

     – JPL: no significant differences

 

For each of the outcomes, the overall quality of improvement was

 

  • OUTCOME #1: Increased discourse informativeness as measured in Correct Information Units (CIU):

strongly effective for MT only

 

  • OUTCOME #2: Increase number of correct sentences in the repetition of trained and untrained sentences:

– trained sentences:

  •   strongly effective for MT
  • moderately effective for RT and ST

– untrained sentences:

  • strongly effective for MT
  • moderate for RT and ST

 

  • OUTCOME #3: Increased diadochokinetic rate (to measure changes in apraxia of speech)—ineffective

 

  • OUTCOME #4: Improved mood as measures using a visual analog procedure— ineffective

 

 

  1. Description of baseline:
  • Were baseline data provided? No. The investigators provided preintervention data but the data were not true baseline data.

 

 

  1. What is the clinical significanceNA. Measures of clinical significance were not provided.

 

 

  1. Was information about treatment fidelity adequate? Not Provided

 

 

  1. Were maintenance data reported? No

 

 

  1. Were generalization data reported? Yes
  • Generalization of repetition of trained to untrained sentences (Outcome #2) was observed in

     – FL: untrained sentences for MT only. Moreover, the improvement in trained versus untrained sentence following MT was not significantly different

 

     – FS: there was significant improvement for untrained sentences for all treatments. However, trained sentences improved significantly more than untrained sentence on RT and ST but not MT

 

     – JPL: there was significant improvement in untrained sentence following MT and RT but not ST. Moreover, trained sentences improved significantly more than untrained sentence following RT but not MT

 

 

  1. Brief description of the design:

 

  • The investigators selected 3 French speaking Ps with Broca’s aphasia to participate in the research delineating the relative contributions of rhythm and pitch to improvements in following MIT.
  • The investigators used a Latin Square Crossover design in which the Ps were assigned to three treatments (MT, RT, ST) in random order. (Each P was administered a different order.)
  • The investigators assessed Ps before and after each treatment phase for a total of 4 testing periods.
  • The outcomes involved measures of discourse informativeness, repetition of trained and untrained (i.e., a generalization measure) stimuli, motor-speech skills (a generalization measure), and mood (a generalization measure.)
  • Statistical analyses involved nonparametric measures in which each P was considered a single case.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: A-

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the relative contribution of rhythm and pitch to the success of MIT

 

POPULATION: Broca’s Aphasia; Adult

 

MODALITY TARGETED: Production

 

 

ELEMENTS OF PROSODY USED AS INTERVENTION: music (rhythm, pitch)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: discourse informativeness, motor speech skills (diadochokinetic rate), repetition of trained and untrained words

 

OTHER TARGETS: mood

 

DOSAGE: 1 hour sessions, 3 days a week, for 6 weeks (18 sessions per intervention)

 

ADMINISTRATOR: graduate students in SLP

 

MAJOR COMPONENTS:

 

  • There were 3 interventions:

– Melodic Therapy (MT)

– Rhythmic Therapy (RT)

– Spoken Therapy (ST)

 

MELODIC THERAPY

 

  • MT was a French adaptation of MIT that included the standard pitch and rhythm changes associated with MIT as well as procedures to promote generalization.

 

  • The clinician (C) produced intoned sentences and directed the P to imitate.

 

  • To facilitate the P’s performance, C instructed P to tap out the rhythm with his left hand.

 

  • At first sentences were produced in unison (C and P.) However, C support was gradually withdrawn until P produced the sentence without intoned models and other cues (e.g., hand tapping.)

 

  • The investigators provided guidelines regarding criteria for progression through the program and corrective feedback.

 

  • Sentence stimuli gradually increased in length and complexity as P progressed through the intervention.

 

RHYTHMIC THERAPY

 

  • RT was a French adaptation of MIT that included only the rhythm changes associated with MIT (i.e., the sentence stimuli were spoken, not intoned.) MT also included procedures to promote generalization.

 

  • The C produced spoken sentences and directed the P to imitate.

 

  • To facilitate the P’s performance, C instructed P to tap out the rhythm with his left hand.

 

  • At first sentences were produced in unison. However, C support was gradually withdrawn.

 

  • The investigators provided guidelines regarding criteria for progression through the program and corrective feedback.

 

  • Sentence stimuli gradually increased in length and complexity as P progressed through the intervention.

 

SPOKEN THERAPY

 

  • ST was a French adaptation of MIT that included only the spoken models associated with MIT as well as procedures to promote generalization.

 

  • C produced spoken sentences and directed the P to imitate.

 

  • At first sentences were produced in unison. However, C support was gradually withdrawn.

 

  • The investigators provided guidelines regarding criteria for progression through the program and corrective feedback.

 

  • Sentence stimuli gradually increased in length and complexity as P progressed through the intervention.

 

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2 Responses to Zumbasen et al. (2014)

  1. Rachel Arntson says:

    Thank you for analyzing this research study, Trish. I don’t remember if there have been any other music related studies that you have looked at. If there are, please let me know. Thanks.

    I’m curious what you think of this study. This delightful professor came up to me last at ASHA a couple of years ago. She told me about her study. I’m not good at knowing what is a good study or not. If you have a chance, I would love your opinion. Dr. Ruth Crutchfield was the professor’s name. She is at the University of Texas – Pan American.

    http://www.aijcrnet.com/journals/Vol_4_No_5_May_2014/2.pdf

    Rachel Arntson

    • Hi Rachel, There is a relatively easy way to access the references concerned with music related review. Just go to the home page of clinical prosody.wordpress.com and check out the dashboard. If you click on “Music and Speech-Language Pathology” you can find abstracts of the reviews associated with music–there are several. I am in the process of cleaning up the page but if the abstract interests you, just like on the link to the review on the Clinical Prosody. Sometimes, there is another link that should take you to a copy of the article. Thank you for reference to Dr. Crutchfield’s study. I will try to access and review it on the blog and contact directly. Best wishes, Trish

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