Theodoros et al. (2016)

 

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

DIP = Dysarthria Impact Profile

EBP = evidence-based practice

f = female

FTF = face-to-face intervention

m = male

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = Patient or Participant

PD =   Parkinson’s Disease

PDQ-39 = Parkinson’s Disease Questionnaire-39

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE: Theodoros, D. G., Hill, A. J., & Russell, T. G. (2016.) Clinical and quality of life outcomes of speech treatment for Parkinson’s Disease delivered to the home via telerehabilitation: A noninferiority randomized controlled trial. American Journal of Speech-Language Pathology, 25, 214-232.

 

REVIEWER(S): pmh

 

DATE: February 7, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY: A- (The highest possible grade for overall quality of this investigation was “A” based on its experimental design, Prospective, Randomized Group Design with Controls.)

 

TAKE AWAY: Australian participants (Ps) with Parkinson’s disease (PD) enrolled in Lee Silverman Voice Treatment either face-to-face (FTF) or online. The FTF and Online interventions resulted in similar changes. Thus, as the result of both Online and FTF LVST, Ps experienced improvement in several loudness outcomes, ease of being understood, and reduced repetition requests. However, significant improvements in the following types of outcomes were not reported: pitch variability, intelligibility, and most quality of life indicators.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Randomized Group Design with Controls

                                                                                                           

  • What was the level of support associated with the type of evidence? Level = A

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups? Yes, in the case where randomization was possible. (See item #4 –names of groups for explanation.)

                                                                   

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from clinicians? No

                                                                    

  • from analyzers? Yes, judges of perceptual measures were blinded.

                                                                    

 

  1. Were the groups adequately described? Yes

 

– How many Ps were involved in the study?

 

  • total # of Ps: 52
  • # of groups: 3
  • List names of groups and the # of participants in each group:
  • Face-to-Face (FTF) Intervention Metro Group n= 16, randomly assigned
  • Online Metro Group n = 15, randomly assigned
  • Online Non-Metro Group n = 21

 

– CONTROLLED CHARACTERISTICS

  • age: between 18 to 89 years
  • vision and hearing: sufficient to participate in investigation via teleconferencing
  • cognitive skills: sufficient to participate in investigation tasks
  • diagnosis: diagnosis of Parkinson’s Disease (PD) from a neurologist; hypokinetic dysarthria associated with PD
  • severity of PD: Stage 1 to 5 on the modified Hoehn and Yahr Scale
  • language: English
  • stimulability: for loud speech (sustained phonation, words, short phrases)
  • vocal structure and function: otolaryngologist reported consistent with PD
  • medication: stable throughout the investigation
  • comorbid neurological disorder other than PD: excluded
  • comorbid speech and language problems not associated with PD: excluded
  • comorbid vocal fold structure and function not associated with PD: excluded
  • comorbid respiratory dysfunction not associated with PD: excluded
  • history of alcohol abuse: excluded
  • diagnosis of dementia: excluded
  • previous experience with LVST: excluded

 

– DESCRIBED CHARACTERISTICS

  • age: overall mean 71.02; range 50-87*
  • gender: overall 36m, 16f*
  • time since diagnosis: overall 0.5 to 22 years*
  • stage of Parkinson’s Disease (PD): range 1 to 5 with majority in Stages 1 to 2.5
  • dysarthria: overallmild (77%), moderate (19%), severe (4%)*

* = no significant difference among the 3 grous

 

–   Were the groups similar before intervention began?

Yes, on the Described Characteristics signified with an asterisk (*) and the monologue Sound Pressure Level (Outcome #3.)

                                                         

– Were the communication problems adequately described? No

  • disorder type: dysarthria associated with PD

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

  • Did each of the groups maintain at least 80% of their original members?

Yes _x__     No ___     Unclear

 

  • Were data from outliers removed from the study? Yes, outliers were removed from the following ratings

     – speech intelligibility

     – articulatory precision

     –   ease of understanding by partner

     – sustained phonation

     – loudness

     – articulatory precision

   – rating of communication on PDQ 39

 

 

  1. Were the groups controlled acceptably? Yes

 

                                                                                                             

  • Was there a no intervention group? No  

                                   

  • Was there a foil intervention group? No

                                   

  • Was there a comparison group? Yes

 

  • Was the time involved in the comparison and the target groups constant? Yes

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

OUTCOMES

 

ACOUSTIC MEASURES:

  • OUTCOME #1: Increased loudness in dB of a sustained phonations
  • OUTCOME #2: Increased loudness in dB of a read passage
  • OUTCOME #3: Increased loudness in dB of a monologue
  • OUTCOME #4: Increased maximum fundamental frequency (F0) in Hz

 

PERCEPTUAL MEASURES:

  • OUTCOME #5: Improved perceived intelligibility
  • OUTCOME #6: Improved perceived pitch variability
  • OUTCOME #7: Improved perceived loudness
  • OUTCOME #8: Improved perceived vocal roughness
  • OUTCOME #9: Improved perceived articulatory precision
  • OUTCOME #10: Improved rating of communicative partner regarding ease of understanding
  • OUTCOME #11: Improved rating of communicative partner regarding the need to ask P for repetitions
  • OUTCOME #12: Improved rating of communicative partner regarding initiating conversation with familiar partners
  • OUTCOME #13: Improved rating of communicative partner regarding initiation conversation with unfamiliar partners
  • OUTCOME #14: Improved overall rating of communicative partner

 

QUALITY OF LIFE MEASURES

  • OUTCOME #15: P’s rating on the Dysarthria Impact Profile (DIP) of the effect of dysarthria on him/her as a person
  • OUTCOME #16: P’s rating on the DIP of his/her acceptance of dysarthria
  • OUTCOME #17: P’s rating on the DIP of how others react to dysarthria
  • OUTCOME #18: P’s rating on the DIP of how dysarthria affects others’ communication with him/her
  • OUTCOME #19: P’s overall rating on the DIP
  • OUTCOME #20: P’s rating on the Parkinson’s Disease Questionnaire-39 (PDQ-39) of overall communication
  • OUTCOME #21: P’s rating on the PDQ-39 of activities of daily living
  • OUTCOME #22: P’s rating on the PDQ-39 of cognition
  • OUTCOME #23: P’s rating on the PDQ-39 of emotion
  • OUTCOME #24: P’s rating on the PDQ-39 of social support
  • OUTCOME #25: P’s rating on the PDQ-39 of stigma
  • OUTCOME #26: P’s rating on the PDQ-39 of bodily discomfort
  • OUTCOME #27: P’s rating on the PDQ-39 of mobility
  • OUTCOME #28: P’s rating on the PDQ-39 summary

 

 

Outcomes 5 through 28 were subjective (i.e., the Perceptual and Quality of Life Outcomes.)

 

Outcomes 1 through 4 were objective (i.e., the Acoustic Outcomes.)

                                         

 

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Yes

  • OUTCOME #5: Improved perceived intelligibility = 0.82
  • OUTCOME #6: Improved perceived pitch variability = 0.36
  • OUTCOME #7: Improved perceived loudness = 0.84
  • OUTCOME #8: Improved perceived vocal roughness = 0.69
  • OUTCOME #9: Improved perceived articulatory precision = 0.83

 

– Intraobserver for analyzers? Yes

There were 2 judges for this task. The results for both are reporteD

  • OUTCOME #5: Improved perceived intelligibility = 0.98; 0.95
  • OUTCOME #6: Improved perceived pitch variability = 0.94; 0.96
  • OUTCOME #7: Improved perceived loudness = 0.90; 0.94
  • OUTCOME #8: Improved perceived vocal roughness = 0.92; 0.98
  • OUTCOME #9: Improved perceived articulatory precision = 0.80; 0.95

 

Treatment fidelity for clinicians? No

 

 

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

 

SUMMARY OF RESULTS

 

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

 

 

TREATMENT AND COMPARISON TREATMENT GROUP ANALYSES

 

ACOUSTIC MEASURES:

  • OUTCOME #1: Increased loudness in dB of a sustained phonations

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #2: Increased loudness in dB of a read passage

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #3: Increased loudness in dB of a monologue (this was considered the primary outcome)

– using noninferiority analysis : it was determined that online treatment was NOT inferior to FTF treatment

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #4: Increased maximum fundamental frequency (F0) range in Hz

– no significant differences were noted for pre and post intervention results or for the different treatment groups

 

 

PERCEPTUAL MEASURES:

  • OUTCOME #5: Improved perceived intelligibility

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #6: Improved perceived pitch variability

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #7: Improved perceived loudness

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #8: Improved perceived vocal roughness

     – no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #9: Improved perceived articulatory precision

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #10: Improved rating of communicative partner regarding ease of understanding

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #11: Improved rating of communicative partner regarding the need to ask P for repetitions

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #12: Improved rating of communicative partner regarding initiating conversation with familiar partners

– no significant differences were noted for pre and post intervention results or for the different treatment groups

 

  • OUTCOME #13: Improved rating of communicative partner regarding initiation conversation with unfamiliar partners

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #14: Improved overall rating of communicative partner

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

 

QUALITY OF LIFE MEASURES

– for 2 of the Quality of Life Measure (listed below)

  • OUTCOME #16: P’s rating on the DIP of his/her acceptance of dysarthria
  • OUTCOME #19: P’s overall rating on the DIP

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

for most the Quality of Life Measures (listed below)   – no significant differences were noted for pre and post intervention results nor for the different treatment groups

  • OUTCOME #15: P’s rating on the Dysarthria Impact Profile (DIP) of the effect of dysarthria on him/her as a person
  • OUTCOME #17: P’s rating on the DIP of how others react to dysarthria
  • OUTCOME #18: P’s rating on the DIP of how dysarthria affects others’ communication with him/her
  • OUTCOME #20: P’s rating on the Parkinson’s Disease Questionnaire-39 (PDQ-39) of overall communication
  • OUTCOME #21: P’s rating on the PDQ-39 of activities of daily living
  • OUTCOME #22: P’s rating on the PDQ-39 of cognition
  • OUTCOME #23: P’s rating on the PDQ-39 of emotion
  • OUTCOME #24: P’s rating on the PDQ-39 of social support
  • OUTCOME #25: P’s rating on the PDQ-39 of stigma
  • OUTCOME #26: P’s rating on the PDQ-39 of bodily discomfort
  • OUTCOME #27: P’s rating on the PDQ-39 of mobility
  • OUTCOME #28: P’s rating on the PDQ-39 summary

 

 

– What statistical tests were used to determine significance?

  • ANOVA:
  • Friedman
  • Kruskal-Wallis
  • Analysis of Noninferiority
  • Chi Square

 

– Were confidence interval (CI) provided? No, but some were reportedly calculated in the statistical analyses.

 

 

  1. What is the clinical significance? NA

 

 

  1. Were maintenance data reported? No

 

  1. Were generalization data reported? Yes

 

  • Several of the measures could be considered generalization data because they are not taught in LVST. Measures which generalized included

– Ease of understanding

– Repetition requests

– Overall rating by communicative partner

– P’s acceptance of his/her dysarthria

– Overall DIP score

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • This was a prospective, randomized group study with controls.
  • The investigators use noninferiority methodology to determine if the targeted intervention (Online LVST) was statistically worse than the established (FTF LVST.)
  • There were 3 groups:

– 2 groups of Ps from the Metro area who were randomly assigned to either FTF or Online interventions

– 1 group of Ps from Rural areas

  • All Ps were tested before and after intervention on a variety measures. The different types of measures included

– Acoustic measures

– Perceptual measures

– Quality of Life measures

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: A-

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To determine if outcomes from Online administration of LVST are equivalent to FTF versions.

 

POPULATION: Parkinson’s Disease; Adults

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, pitch variation

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: intelligibility, vocal roughness, articulatory precision

OTHER TARGETS: Quality of life indicators

 

DOSAGE: 1 hour a day, 4 days a week, 4 weeks, for 1 month

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

  • The major components of the procedures will be discussed in 3 sections:

– LVST summary

– Online procedures

– FTF procedures

 

LVST SUMMARY

 

  • Purpose of LVST: to increase loudness and phonatory effort

 

  • Structure of Sessions:

– Repetitive Drills

  • Sustained Phonation
  • Pitch Range
  • Maximum loudness in functional speech

 

– Functional Speech Activities

 

– Assignment of Homework

 

 

ONLINE PROCEDURES

 

  • C administered the intervention in the home. P was linked to the C using videoconferencing.

 

  • Before intervention, the investigator taught P to use the videoconferencing equipment.

 

 

FTF PROCEDURES

 

  • C administered the intervention in a clinic room at the research institution

 

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