Marshall & Holtzapple (1978)

 

EBP THERAPY ANALYSIS for

Single Case Designs

NOTES:

  • 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

MIT = Melodic Intonation Therapy:

NA = not applicable

P = Patient or Participant

P = Porch Index of Communicative Ability

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE: Marshall, N., & Holtzapple, P. C. (1978). Melodic Intonation Therapy: Variations on a theme. In R. Brookshire (Ed.), Clinical aphasiology collected proceedings 1972-1976 (pp. 285-308.) Minneapolis: BRK Publications.

 

REVIEWER(S): pmh

 

DATE: October 16, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: D

 

TAKE AWAY: These illustrative case studies are reviewed to focus attention on the history of music in speech-language pathology and to describe modifications (M-Modification) of Melodic Intonation Therapy (MIT) that may be used when patients (Ps) do not response to traditional MIT. The P who received traditional MIT did not evidence improvement on Porch Index of Communicative Abilities (PICA) scores from pre to post intervention; however, he did produce noticeable improvement on PICA modality scores and on cell scores as well as improvement on PICA scores 3 and 6 months post intervention. The other 3 Ps, who were administered M-Modification, displayed varying degrees of success

 

 

  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 Studies – Program Description(s) with Case Illustration(s) xxx

                                                                                                           

  • 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? No

 

 

  1. Were the participants (Ps) adequately described? Variable

 

– How many Ps were involved in the study? 4

 

– The P characteristics/variables that were DESCRIBED included

  • age:

Mr. E.: 49 years

     – Mr. G. V.: 49 years

     – Mr. G. B.: 53 years

Mr. J. W.: 41 years

 

  • gender: all 3 participants (Ps) were male

                                                           

  • expressive language: Porch Index of Communicative Ability (PICA) score during baseline yielded

Mr. E.:

  • Overall PICA – approximately 45
  • Gestural PICA – approximately 55
  • Verbal PICA – approximately 37
  • Graphic PICA – approximately 60

 

     – Mr. G. V.:

  • Overall PICA – approximately 42
  • Gestural PICA – approximately 50
  • Verbal PICA – approximately 35
  • Graphic PICA – approximately 50

 

     – Mr. G. B.:

  • Overall PICA – approximately 45
  • Gestural PICA – approximately 68
  • Verbal PICA – approximately 30
  • Graphic PICA – approximately 68

 

– Mr. J. W.:

  • Overall PICA – approximately 38
  • Gestural PICA – approximately 34
  • Verbal PICA – approximately 22
  • Graphic PICA – approximately 63

 

  • diagnosis:

Mr. E.: aphasia and right hemiplegia

     – Mr. G. V.: aphasia and right hemiplegia

     – Mr. G. B.: marked aphasia, severe apraxia, minimal dysarthria, right hemiplegia

– Mr. J. W. : severe apraxia and aphasia

  • site of lesion/etiology/additional medical information:

Mr. E.: left hemisphere artery thrombosis

     – Mr. G. V.: small hemorrhage of lenticulostriate artery and left internal capsule and basal ganglia; in coma for 12 days

     – Mr. G. B.: left middle cerebral artery thrombosis

– Mr. J. W.: left thromboembolic cerebrovascular accident

 

  • time post onset when MIT or M-Modification was initiated:

Mr. E.: 9 months

     – Mr. G. V.: 27 months

     – Mr. G. B. : 4.5 months (traditional MIT had been tried)

– Mr. J. W.: 1 month

 

  • Form of Melodic Intonation Therapy (MIT) administered:

Mr. E.: traditional MIT

     – Mr. G. V.: M- Modification

     – Mr. G. B. : M- Modication

– Mr. J. W.: M- Modification

                                                 

4c Were the communication problems adequately described?

Yes_x__   No ___   Unclear/Variable _________                   

  • List the disorder type(s):

Mr. E.: moderate apraxia and aphasia

     – Mr. G. V.: aphasia

     – Mr. G. B.: marked aphasia, severe apraxia, minimal dysarthria

     – Mr. J. W.: severe aphasia, severe apraxia

 

  • Other aspects of impaired communication

Mr. E.: usually could imitate single words, mild prosodic impairment, naming usually unintelligible or rejected, initiation characterized by struggle behaviors and production of a variety of speech sounds.

     – Mr. G. V.: jargon with an occasional intelligible word

   – Mr. G. B.: no additional description of communication skills

Mr. J. W.: no additional description of communication skills

 

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Yes, these were case studies

 

  • 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

 

 

  1. Did the design include appropriate controls? No, these were case studies,

                                                                      

  • Were baseline/preintervention data collected on all behaviors? Yes

 

  • Did probes/intervention data include untrained stimuli? No

 

  • Did probes/intervention data include trained stimuli? Yes

 

  • Was the data collection continuous?  No

 

  • Were different treatment counterbalanced or randomized? NA

 

 

  1. Were the outcome measures appropriate and meaningful? Yes

 

– The outcomes were

 

  • OUTCOME #1: Overall performance on the PICA

 

  • OUTCOME #2: Performance on the Gestural portions of the PICA

 

  • OUTCOME #3: Performance on the Verbal portions of the PICA

 

  • OUTCOME #4: Performance on the Graphic portions of the PICA

 

  • OUTCOME #5: Performance on the cell scores (intelligibility, struggle behavior) of the PICA (for only one case, Mr. E.)

 

All the outcomes that were subjective.

                                                       

– None of the outcomes were objective

 

None of the outcome measures were associated with reliability data.

 

 

  1. Results:

 

Did the target behaviors improve when treated? Variable

 

The overall quality of improvement for each of the outcomes was

 

NOTE: All 4 cases were analyzed descriptively and served as illustrations to the authors’ description of their modifications to the traditional version of MIT (i.e., M-Modification.) Mr. E.’s case is an example of a patient (P) who successfully completed MIT intervention and who was not administered M-Modification. The other cases serve as illustrations of Ps who received M-Modification.

 

– Mr. E. (p. 287): Illustrative Case for the Use of Traditional MIT

 

  • OUTCOME #1: Overall performance on the PICA—no change from pre to post testing– ineffective

 

  • OUTCOME #2: Performance on the Gestural portions of the PICA—6% point decrease from pre to post testing–small

 

  • OUTCOME #3: Performance on the Verbal portions of the PICA— small (3% points) positive change of from pre to post testing

 

  • OUTCOME# 4: Performance on the Graphic portions of the PICA—6% point decrease from pre to post testing– small

 

  • OUTCOME #5: Performance on the cell scores (intelligibility, struggle behavior) of the PICA

—Prior to administration of traditional MIT, P’s verbal responses were largely unintelligible; following MIT, P did not produce any unintelligible verbal responses on the PICA; average cell score increase 1.2 points from pre to post intervention testing—moderate

     —Prior to administration of traditional MIT, P was described as producing intense struggle behavior; following MIT, P’s struggle behavior was described as minimal.

 

 

– Mr. G. V. (p. 302): Illustrative case for the use of M-Modification of MIT (Plans I, II, and III.)

 

  • OUTCOME #1: Overall performance on the PICA—increased approximately 8% points; all Mr. G. V.’s responses on Subtest I of the PICA were intelligible although the investigators reported aphasic errors-small

 

  • OUTCOME #2: Performance on the Gestural portions of the PICA —increased approximately 10% points– moderate

 

  • OUTCOME #3: Performance on the Verbal portions of the PICA—increased approximately 5% points–small

 

  • OUTCOME $4: Performance on the Graphic portions of the PICA—increased approximately 2% points- negligible

 

 

– Mr. G. B. (p. 303A): Illustrative Case of M-Modification of MIT (Plan 1)

 

  • OUTCOME #1: Overall performance on the PICA—increased approximately 5% points—small

 

  • OUTCOME #2: Performance on the Gestural portions of the PICA——decreased approximately 12% points–moderate

 

  • OUTCOME #3: Performance on the Verbal portions of the PICA–increased approximately 5% points–small

 

  • OUTCOME #4: Performance on the Graphic portions of the PICA— score remained the same–ineffective

 

 

 

– Mr. J. W. (p. 306): Illustrative Case for the use of M-Modification of PICA (Plans I and III); the final PICA was administered about ½ way through the M-Modification treatment.

 

  • OUTCOME #1: Overall performance on the PICA—score increased about 10% points from preintervention PICA until PICA administered in the middle of treatment–moderate

 

  • OUTCOME #2: Performance on the Gestural portions of the PICA—score increased about 5% points from preintervention PICA until PICA administered in the middle of treatment– small

 

  • OUTCOME #3: Performance on the Verbal portions of the PICA—score increased about 10% points from preintervention PICA until PICA administered in the middle of treatment– moderate

 

 

  • OUTCOME $4: Performance on the Graphic portions of the PICA—score increased about 14% points from preintervention PICA until PICA administered in the middle of treatment– moderate

 

 

  1. Description of baseline:

 

  • Were baseline data provided? Yes

 

Mr. E.:

  • Overall PICA – approximately 45, low and stable
  • Gestural PICA – approximately 55, moderate and stable
  • Verbal PICA – approximately 37, low and stable
  • Graphic PICA – approximately 60, moderate and stable

 

     – Mr. G. V.:

  • Overall PICA – approximately 42, low and stable
  • Gestural PICA – approximately 50, moderate and stable
  • Verbal PICA – approximately 35, low and stable
  • Graphic PICA – approximately 50, moderate and stable

 

     – Mr. G. B.:

  • Overall PICA – approximately 45, low and stable
  • Gestural PICA – approximately 68, moderate and stable
  • Verbal PICA – approximately 30, low and stable
  • Graphic PICA – approximately 68, moderate and stable

 

– Mr. J. W.:

  • Overall PICA – approximately 38, low and stable
  • Gestural PICA – approximately 34, low and stable
  • Verbal PICA – approximately 22, low and stable
  • Graphic PICA – approximately 63, moderate and stable

 

 

  • Was the percentage of nonoverlapping data (PND) provided? No

 

 

  1. What is the clinical significance?  NA

 

 

  1. Was information about treatment fidelity adequate? No

 

 

  1. Were maintenance data reported? Yes

 

– Mr. E.: Illustrative Case for the Use of Traditional MIT; Maintenance was tested 3 months and 6 months after post intervention testing

 

  • OUTCOME #1: Overall performance on the PICA—increased about 6% points at 3 months post intervention compared to post intervention score; increased about 5% points at 6 months post intervention compared to post intervention score

 

  • OUTCOME #2: Performance on the Gestural portions of the PICA—increased about 4% points at 3 months post intervention compared to post intervention score; no change at 6 months post intervention compared to post intervention score

 

  • OUTCOME #3: Performance on the Verbal portions of the PICA—increased about 7% points at 3 months post intervention compared to post intervention score; increased about 7% points at 6 months post intervention compared to post intervention score

 

  • OUTCOME 4: Performance on the Graphic portions of the PICA—increased about 67% points at 3 months post intervention compared to post intervention score; increased about 5% points at 6 months post intervention compared to post intervention score

 

  • OUTCOME 5: Performance on the cell scores of the PICA

— Average cell score on Subtest 1 of the PICA increased 0.1 from post intervention testing at 3 months post intervention; Average cell score on Subtest 1 of the PICA increased 1.3 from post intervention testing at 6 months post intervention

     — Struggle behaviors reemerged following the termination of direct MIT.

 

 

– Mr. G. V.: Illustrative case for the use of M-Modification of MIT (Plans I, II, and III); Maintenance was tested 3 months after post intervention testing

 

  • OUTCOME #1: Overall performance on the PICA—slight decrease from post intervention testing

 

  • OUTCOME #2: Performance on the Gestural portions of the PICA—slight decrease from post intervention testing

 

  • OUTCOME #3: Performance on the Verbal portions of the PICA—slight decrease from post intervention testing

 

  • OUTCOME $4: Performance on the Graphic portions of the PICA—no change from post intervention testing

 

 

– Mr. G. B.: Illustrative Case of M-Modification of MIT (Plan I)—Maintenance data not were collected.

 

– Mr. J. W. (p. 306): ): Illustrative Case of M-Modification of MIT (Plans I and III)—Maintenance data not were collected.

 

 

  1. Were generalization data reported? No

 

  1. Brief description of the design:

 

All 4 cases were analyzed descriptively and served as illustrations to the authors description of their modifications to the traditional version of MIT (i.e., M-Modification.) Mr. E.’s case is an example of a patient (P) who successfully completed MIT intervention and who was not administered M-Modification. The other cases serve as illustrations of Ps who received M

 

 

ASSIGNED OVERALL GRADE OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To describe modifications (M-Modification) to MIT and their effectiveness.

 

POPULATION: Aphasia, Apraxia; Adults

 

MODALITY TARGETED: production

 

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

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED (Dependent variable): Performance on the PICA, intelligibility (Mr. E. E.), struggle behavior (Mr. E. E.)

 

DOSAGE: Varied among the Ps:

– Mr. E. (p. 287): administered traditional MIT—3 months

– Mr. G. V. (p. 302): administered M-Modification Plans I, II, III – 3 ½

months, 3 times a week, 5 hours a week (some of this was group therapy)

– Mr. G. B. (p. 303A): administered M-Modification Plan I—approximately 1 month (incomplete data)

– Mr. J. W. (p. 306): administered M-Modification Plans I, III—approximately 4 months (incomplete data)

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

  • The summary presents the 3 modification plans (Plans I, II, and III) for MIT. The decision regarding which plan(s) to use was based on the characteristics of the P. Because the authors’ focus was M-Modification, Traditional MIT is not summarized here even though it was one of the treatments discussed by the authors.

 

  • Stimuli for the plans were standard intoned sentences with one of 5 common nouns (i.e., intoned sequence units or ISUs.)

 

  • The criterion for moving from step-to-step within the plans is

– 3/3 correct/acceptable responses using a specific ISU.

– If 2 of the 3 responses are correct and the third response is only marginally correct, 2 consecutive additional responses can be considered as reaching criterion.

– If criterion is not met, the clinician (C) returns to the last step in which the ISU was acceptable.

– If P fails to reach criterion on 3 attempts, the particular ISU is discarded.

 

  • These modifications of MIT were designed for Ps who struggled with the Traditional MIT.

 

  • The authors noted that Cs should use hand signals and rhythmic tapping, as is standard in the Traditional MIT. However, they did not detail how to accomplish this with Plans I, II, and III.

 

  • Ideally, Plans I and II should be implemented sequentially. Plan III can be implemented at any time.

 

 

PLAN I

 

OBJECTIVE: To answer questions using standard intoned sentence structure (intoned sequence unit—ISU) with one of five nouns.

 

PROCEDURES:

 

  1. The clinician (C) presents written stimuli and models the ISU (e.g., “It’s a watch,” “It’s a coke,” (p. 297) and directs the participant (P) to listen and read.

 

  1. Same as Step A, but C directs P to observe his/her mouth “Listen and watch my mouth.”

 

  1. C presents written ISU and directs P to intone the ISU in unison with him/her: “Let’s sing it together—3 times.” (p. 297)

 

  1. C presents the ISU in print and directs P to say the first word in unison with him/her but then continue the ISU alone while watching C mouth the words: “We’ll do the first word together, then you’re on your own—but watch my mouth for hints” (p. 297.)

 

  1. C presents a written version of the ISU and directs P to say the first word with him/her and continue saying the whole sentence. C also fades out visual support (mouthing): “Now we’ll do the first word together, then you’re on your own” (p. 297.)

 

  1. C presents a written version of the ISU, models the production of the ISU, and directs P to intone it 3 times: “Listen while I sing it once, then you repeat it after me – 3 times” (p. 297.)

 

  1. C models the production of the ISU, and directs P to intone it 3 times after a delay: “Listen while I sing it once—wait a few seconds– then you try it 3 times” (p. 297.)

 

  1. C intones questions and P responds using the ISU. “I am going to ask you 3 questions and I want you to answer the sentence we just practiced” (p. 297.)

 

 

PLAN II

 

OBJECTIVE: To answer questions using an ISU with a variety of nouns that have not been presented in Plan I

 

  1. C models a written word (i.e., a core word) presented to P and directs P to repeat a word 5 times. Although the word is presented in its written form, C does not attempt to draw P’s attention to the written form. C can provide cues as need: “I want you listen, then this word after me —5 times. Say core word” (p. 300.)

 

  1. C produces and presents in written form an ISU containing the core word from A while directing P to observe facial cues: “Listen and watch my mouth” (p. 300.) For example, if the word from A had been “cane,” the ISU could be “Get my cane.”

 

  1. C presents the ISU in a written format and direct P to intone the ISU in unison with him/her: “Okay, now let’s sing it together 3 times” (p. 300.)

 

  1. C presents a written version of the ISU and directs P to intone the first word of the ISU in unison but provides no additional cues: “Now we’ll do the first word together, then you’re on your own” (p. 300.)

 

  1. C presents the ISU in written form, models the ISU, and directs P to repeat the ISU 3 times: “I’ll sing it once, then you sing it after me—3 times” (p. 300.)

 

  1. C presents the written version of the ISU, models the ISU, and directs P to wait and then intone the ISU 3 times: “Now, I’ll sing it once, we’ll wait a few seconds, then you sing the sentence 3 times” (p. 300.)

 

  1. C intones questions and P responds using an appropriate ISU: “I want you to answer my questions using the sentence we just practiced” (p. 300.) For example, C asks: “What do you want?” and P responds: “Get my cane.”

 

 

PLAN III

 

OBJECTIVE: To imitate an ISU and/or other phrases presented on the Language Master.

 

  1. P practices using written sentence and a Language Master.

 

  1. P listens, repeats, and copies the targeted sentences.

 

  1. The sentences vary from previously trained ISU to novel phrases.

– If Plan III is used simultaneously with Plan I, the targets should be trained ISUs.

– If Plan III is used simultaneously with Plan II, the targets should be new, not previously trained ISUs.

 

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