Park et al. (2016)

 

EBP THERAPY ANALYSIS

Treatment Group

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

Key:

ASSIDS = Assessment of Intelligibility of Dysarthric Speech (ASSIDS)

C = Clinician

CER = communication efficiency ratio

DIP = Dysarthria Impact Profile

EBP = evidence-based practice

f = female

m = male

KP feedback = Knowledge of Production (KP) feedback

KR feedback = Feedback Knowledge of Results (KR) feedback

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

WPM = words per minute

 

 

SOURCE: Park, S., Theodoros, D., Finch, E., & Cardell, E. (2016). Be Clear: A new intensive speech treatment for adults with nonprogressive dysarthria. American Journal of Speech-Language Pathology, 25, 97-110.

 

REVIEWER(S): pmh

 

DATE: January 14, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY: C (The highest possible overall grade for this investigation was C+ based on its experimental design: prospective, single group, pretest vs posttest.)

 

TAKE AWAY: This preliminary investigation determined the feasibility of using Clear Speech as a treatment for adults with nonprogressive dysarthria. The results indicated that there was statistical or clinical improvement in 8 participants’ (Ps) intelligibility and some improvements in perceived (by P or by a communicative partner) communication status. It should be noted that statistical and clinical interpretations did not always agree. In addition, there was a decrease in speaking rate for the Ps.

 

 

  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 clinician? No

                                                                    

  • from analyzers? Yes, perceptual analysis of conversational samples, ratings of sentence intelligibility, and ratings of word intelligibility involved listeners who were blinded to the timing of the elicitation of the samples.

                                                                    

 

  1. Was the group adequately described? Yes

 

– How many Ps were involved in the study?

  • total # of Ps:   8
  • # of groups: 1
  • List names of groups and the # of participants in each group: NA

 

– CONTROLLED CHARACTERISTICS

  • cognitive skills: SLP judged P to have sufficient cognition to participate; no dementia
  • language skills: “able to speak and understand English” (p. 100); no aphasia or apraxia of speech
  • diagnosis: dysarthria by a speech-language pathologist (SLP)
  • post onset time: at least 6 months
  • stimulability: pretreatment assessment reveal P was stimulable for Clear Speech
  • hearing: no significant loss
  • vision: no significant loss

 

– DESCRIBED CHARACTERISTICS

  • age: 18 – 51 years (mean = 35 years_
  • gender: 5m, 3f
  • cognitive skills: 7Ps had documented cognitive problems that were not judged to interfere with the treatment. The types of cognitive problems are listed; most Ps had multiple cognitive impairments:

     – divided attention

     – memory

     – verbal fluency

     – visual memory

     – visuo-spatial memory

     – processing speed

     – complex planning and problem solving

     – planning

     – verbal concepts

     – mental control

     – recall

     – attention

     – organization

  • diagnosis: persistent nonprogressive dysarthria
  • neurological condition:

– Traumatic Brain Injury = 6

     – Stroke = 2

  • post onset time: 10 – 72 months (mean = 26 months)
  • previous therapy: all Ps had previously received therapy

 

Were the communication problems adequately described?

 

  • disorder type: nonprogressive dysarthria; types of dysarthria

– flaccid- ataxic (2)

– ataxic (3)

– spastic-ataxic (1)

– hypokinetic (1)

– spastic (1)

  • functional level: mild to severe

 

 

  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 due to instrumentation issues some of the analyses were not complete:

     – P5 had only 1 pretreatment sample

     – P2 had only 1 posttreatment sample

     – P4 had only 1 follow up sample

 

 

  1. Were the groups controlled acceptably? NA, there was only one group.

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

– OUTCOMES

 

PERCEPTUAL MEASURES

  • OUTCOME #1: Improved rating of intelligibility (i.e., clearer or easier to understand) of speech samples.
  • OUTCOME #2: Improved percentage of word intelligibility on the Assessment of Intelligibility of Dysarthric Speech (ASSIDS)
  • OUTCOME #3: Improved percentage of sentence intelligibility on the ASSIDS
  • OUTCOME #4: Improved speaking rate (words per minute, WPM) derived from the sentence intelligibility portion of ASSIDS
  • OUTCOME #5: Improved communication efficiency ratio (CER; rate of intelligible words minute divided by 190)
  • OUTCOME #6: Improved self-rating for the total score of the Dysarthria Impact Profile (DIP)
  • OUTCOME #7: Improved self -rating for the Section A score of the DIP (effect of dysarthria on P)
  • OUTCOME #8: Improved self- rating for the Section B score of the DIP (acceptance of dysarthria)
  • OUTCOME #9: Improved self- rating for the Section C score of the DIP (how P perceives other react to his/her speech)
  • OUTCOME #10: Improved self- rating for the Section D score of the DIP (how dysarthria affects communication with others)
  • OUTCOME #11: Improved self-rating for the Section E score of the DIP (concerns about dysarthria compared to other possible concerns)
  • OUTCOME #12: Improved rating on communication partner questionnaire for question about understanding the P
  • OUTCOME #13: Improved rating on communication partner questionnaire for question about requests for repetition of P’s speech
  • OUTCOME #14: Improved rating on communication partner questionnaire for question about P’s conversational initiations with familiar individuals
  • OUTCOME #15: Improved rating on communication partner questionnaire for question about P’s conversational initiations with strangers
  • OUTCOME #16: Improved rating on communication partner questionnaire for question about P’s overall communication

 

ALL the outcome measures were subjective.

 

NONE of the outcome measures were objective.

                                         

 

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Yes

 

  • OUTCOME #2: Improved percentage of word intelligibility on the Assessment of Intelligibility of Dysarthric Speech (ASSIDS)—investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

  • OUTCOME #3: Improved percentage of sentence intelligibility on the ASSIDS —investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

  • OUTCOME #4: Improved speaking rate (words per minute, WPM) derived from the sentence intelligibility portion ASSIDS —investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

  • OUTCOME #5: Improved communication efficiency ratio (CER; rate of intelligible words minute divided by 190) —investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

Intraobserver for analyzers?

 

  • OUTCOME #2: Improved percentage of word intelligibility on the Assessment of Intelligibility of Dysarthric Speech (ASSIDS) )—investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

  • OUTCOME #3: Improved percentage of sentence intelligibility on the ASSIDS)—investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

  • OUTCOME #4: Improved speaking rate (words per minute, WPM) derived from the sentence intelligibility portion ASSIDS)—investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

  • OUTCOME #5: Improved communication efficiency ratio (CER; rate of intelligible words minute divided by 190) —investigators cited previous literature in which interrater, intrarater, and test-retest reliability had been established

 

– Treatment fidelity for clinicians? No

 

 

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

 

— What level of significance was required to claim significance?

  • for inferential statistical analyses p ≤ 0.05
  • for descriptive analysis (clinical significance)

∞ for word intelligibility — gains ≥ 3.2%

∞ for sentence intelligibility – gains ≥ 8.6%

 

PRE AND POST TREATMENT ANALYSES

 

  • OUTCOME #1: Improved rating of intelligibility (i.e., clearer or easier to understand) of speech samples.
  • At post test, 72% of the Ps were rated as easier to understand than the pretreatment sample

 

  • OUTCOME #2: Improved percentage of word intelligibility on the Assessment of Intelligibility of Dysarthric Speech (ASSIDS)
  • differences were not significantly different across testing times (pre, post, follow-up)
  • Clinically significant improvement was achieved for posttreatment

 

  • OUTCOME #3: Improved percentage of sentence intelligibility on the ASSIDS
  • Significant differences across the 3 testing times (pre, post, follow-up)
  • Posttreatment was significantly better than pretreatment

 

  • OUTCOME #4: Improved speaking rate (words per minute, WPM) derived from the sentence intelligibility portion ASSIDS
  • Significant decrease from pretreatment to posttreatment
  • Criteria for clinical significance were not reached for posttreatment and for follow-up

 

  • OUTCOME #5: Improved communication efficiency ratio (CER; rate of intelligible words minute divided by 190)
  • differences were not significantly different or clinically significant across testing times (pre, post, follow-up)

 

  • OUTCOME #6: Improved self-rating for the total score of the Dysarthria Impact Profile (DIP)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #7: Improved self -rating for the Section A score of the DIP (effect of dysarthria on P)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #8: Improved self- rating for the Section B score of the DIP (acceptance of dysarthria)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #9: Improved self- rating for the Section C score of the DIP (how P perceives other react to his/her speech)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #10: Improved self- rating for the Section D score of the DIP (how dysarthria affects communication with others)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #11: Improved self-rating for the Section E score of the DIP (concerns about dysarthria compared to other possible concerns)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #12: Improved rating on communication partner questionnaire for question about understanding the P
  • Compared to pretreatment, Ps were rated as significantly easier to understand at posttreatment but not at follow-up
  • OUTCOME #13: Improved rating on communication partner questionnaire for question about requests for repetition of P’s speech
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #14: Improved rating on communication partner questionnaire for question about P’s conversational initiations with familiar individuals
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #15: Improved rating on communication partner questionnaire for question about P’s conversational initiations with strangers
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #16: Improved rating on communication partner questionnaire for question about P’s overall communication
  • Compared to pretreatment, Ps were rated as significantly better communicator at posttreatment and at follow-up.

 

 

— What were the statistical tests used to determine significance? Wilcoxon; Friedman’s two way analysis of ranks

 

— Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance(List outcome number with data with the appropriate Evidence Based Practice, EBP, measure.) NA. No tests of clinical significance were reported. Rather, the authors descriptively cited criteria for claiming clinical significance. These findings are reported in the descriptive data associate with item #9.

 

 

  1. Were maintenance data reported? Yes

 

 

  • OUTCOME #1: Improved rating of intelligibility (i.e., clearer or easier to understand) of speech samples.
  • At follow up, 64% of the Ps were rated as easier to understand than the pretreatment sample

 

  • OUTCOME #2: Improved percentage of word intelligibility on the Assessment of Intelligibility of Dysarthric Speech (ASSIDS)
  • differences were not significantly different across testing times (pre, post, follow-up)
  • Clinically significant improvement was achieved for follow-up

 

  • OUTCOME #3: Improved percentage of sentence intelligibility on the ASSIDS
  • Significant differences across the 3 testing times (pre, post, follow-up)
  • Significant progress was maintained at follow up
  • OUTCOME #4: Improved speaking rate (words per minute, WPM) derived from the sentence intelligibility portion ASSIDS
  • Significant decrease from pretreatment to follow – up
  • Criteria for clinically significant were not reached for posttreatment and for follow-up

 

  • OUTCOME #5: Improved communication efficiency ratio (CER; rate of intelligible words minute divided by 190)
  • differences were not significantly different or clinically significant across testing times (pre, post, follow-up)

 

  • OUTCOME #6: Improved self-rating for the total score of the Dysarthria Impact Profile (DIP)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #7: Improved self -rating for the Section A score of the DIP (effect of dysarthria on P)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #8: Improved self- rating for the Section B score of the DIP (acceptance of dysarthria)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #9: Improved self- rating for the Section C score of the DIP (how P perceives other react to his/her speech)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #10: Improved self- rating for the Section D score of the DIP (how dysarthria affects communication with others)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #11: Improved self-rating for the Section E score of the DIP (concerns about dysarthria compared to other possible concerns)
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #12: Improved rating on communication partner questionnaire for question about understanding the P
  • Compared to pretreatment, Ps were rated as significantly easier to understand at posttreatment but not at follow-up
  • OUTCOME #13: Improved rating on communication partner questionnaire for question about requests for repetition of P’s speech
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #14: Improved rating on communication partner questionnaire for question about P’s conversational initiations with familiar individuals
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #15: Improved rating on communication partner questionnaire for question about P’s conversational initiations with strangers
  • No significant changes were noted across testing times (pre, post, follow-up)

 

  • OUTCOME #16: Improved rating on communication partner questionnaire for question about P’s overall communication
  • Compared to pretreatment, Ps were rated as significantly better communicator at posttreatment and at follow-up.

 

 

  1. Were generalization data reported? No __x___     Not clear _____

If yes, summarize findings

 

 

  1. Describe briefly the experimental design of the investigation.
  • This preliminary investigation was designed as a Phase II feasibility trial. Its purpose was to determine if

– treatment can be completed within the targeted time frame

– the intensive treatment schedule is appropriate for the Ps

– there is some evidence of improved intelligibility among the Ps

– if there is a need to modify Clear Speech procedures

 

  • Eight speakers diagnosed with nonprogressive dysarthria served as Ps.

 

  • The Ps were assessed 3 times: pretreatment, posttreatment, and follow-up (1 to 3 months following the termination of Clear Speech intervention.)

 

  • There were 2 major classes of outcomes: Perceptual Assessments and Everyday Communication Assessments.

 

  • The Perceptual Assessments were administered 2 times during each of the 3 assessment phases. The Perceptual Assessment included:

– Intelligibility judgments of short speech samples by blinded naïve listeners .

– Administration of ASSIDS which tapped word intelligibility, sentence intelligibility, WPM, and CER.

 

  • The Everyday Communication Assessment were administered only 1 time during each of the 3 assessment phases. The Everyday Communication Assessment explored the Ps’ and Ps’ communicative partners perceptions of the Ps communication status.

 

  • The statistical analyses involved nonparametric and descriptive statistics including a measure of clinical significance. Paired comparisons were of pretreatment vs posttreatment and pretreatment vs follow-up. Not sure why they did not do post vs follow up.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: The purpose of this preliminary investigation was to determine the feasibility of using Clear Speech intervention.

 

POPULATION: dysarthria (nonprogressive); Adults

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: rate of speech

 

ELEMENTS OF PROSODY USED AS INTERVENTION: “decreased speech rate, increased fundamental frequency and frequency range, increased pause frequency and duration, increased sound pressure level….” (p. 98)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: intelligibility, perceived communication status

 

DOSAGE: 17 one-hour sessions (16 of the sessions, the Intensive Practice Phase, were administered 4 times a week for 4 weeks)

 

ADMINISTRATOR: SLP (the lead author administered all therapy)

 

MAJOR COMPONENTS:

 

  • There were 2 phases: Prepractice Phase (1 session) and the Intensive Practice Phase (16 sessions)

 

PREPRACTICE PHASE (1 session)

  • The clinician (C) worked with the P to confirm that he/she

– could follow the Clear Speech treatment protocol

– understood what clear speech sounded like

– could produce clear speech with the assistance of C’s shaping and stimulation, if necessary

 

  • To establish P’s understanding of the targeted behavior (i.e., clear speech), P viewed a video in which

– P identified the clearest speech,

– P described characteristics that were associated with the clearest speech (e.g., slow speech), and

– P then read aloud a passage while trying to replicate strategies observed in the video.

 

  • C used the following techniques to elicit correct responses from Ps.

– modeling

– Knowledge of Production (KP) Ffeedback which was used to shape behaviors. C described behaviors that might enable P to produce the targeted clear speech (e.g., “Slow down,” “Pause between phrases.”)

 

 

INTENSIVE PRACTICE PHASE (16 sessions)

  • There were 3 components in each Intensive Practice Phase session: Brief Prepractice Component, Intensive Practice Component, and Homework.

 

 

Brief Prepractice Component of the Intensive Practice Phase

 

  • C directed P to read aloud target sentences using clear speech.

 

  • C shaped P’s production using modeling and KP feedback.

 

  • C moved P into the next component when he/she produced the target sentences with adequate clear speech.

 

Intensive Practice Component of the Intensive Phase

 

  • The Intensive Practice Component of the Intensive Phase had 2 parts: structured speech drill and functional speech tasks.

 

– Structured Speech Drill

 

  • Using a constant set of sentences, C imitated

– 10 sentences concerned with daily living 5 times using clear speech and

– 10 sentences requesting service 5 times using clear speech.

 

  • C provided Knowledge of Results (KR) Feedback (e.g., “clear” or “unclear”) to the P.

 

– Functional Speech Tasks

 

  • The functional tasks included

– reading aloud,

– describing pictures, and

– conversing with others.

 

  • C administered the tasks in random order with P attempting up to 3 times to produce the targeted speech using clear speech.

 

  • The targeted stimuli changed for each session.

 

  • C directed P to focus on his/her productions (or “acoustic speech signal’) when attempting to produce clear speech.

 

  • C also encouraged self-monitoring (or “self-evaluation) by

– recording P’s production,

– playing back the productions to P at intermittent intervals,

– and directing P to rate his/her clarity

 

  • C provided KR feedback to the P.

 

Homework

 

  • C assigned 15 minutes of daily homework.

 

  • During the intervention, homework was expected to be executed each day and comprised practicing

– functional phrases,

– requests for service,

– functional speech task stimuli, as well as

– using their skill in daily living activities.

 

  • When intervention had been terminated, C requested Ps to practice the same activities for about 10 minutes 3 to 5 days a week.

 

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