Duffy et al. (2015)

EBP THERAPY ANALYSIS for
Single Case Designs

Key:
AMRs = Alternating Motion Rates
AOS = Apraxia of Speech
ASRS = Apraxia of Speech Rating Scale
C = Clinician
EBP = evidence-based practice
FDG-PET = Flurodeoxglucose-positron emission tomography
MMSE = Mini-Mental State Examination
MRI = Magnetic Resonance Imaging
MSD – Severity Rating of functional speech severity on a 10-point scale
NA = not applicable
P = Patient or Participant
P1 = Participant #1
P2 = Participant #2
pmh = Patricia Hargrove, blog developer
PPA = Primary Progressive Aphasia
PPAOS = Primary Progressive Apraxia of Speech (PPAOS)
PVI = Pairwise Variability Index (PVI)
SLP = speech–language pathologist
SMRs = Sequential Motion Rates (SMRs)
WAB = Western Aphasia Battery
WAB- AQ = Western Aphasia Battery -Aphasic Quotient

SOURCE: Duffy, J. R., Strand, E. A., Clark, H., Machulda, Whitwell, J. L., & Josephs, K. A. (2015). Primary progressive apraxia of speech: Clinical features and acoustic and neurologic correlates. American Journal of Speech-Language Pathology, 24, 88-100.

REVIEWER(S): pmh

DATE: May 7, 2017

ASSIGNED OVERALL GRADE: No overall grade assigned; this is not an intervention study.

TAKE AWAY: Two case studies revealed that certain prosodic measures (duration, rate, pauses, segmentation, and stress) as well as nonprosodic measures deteriorate over time in patients diagnosed with Primary Progressive Apraxia of Speech.

– What was the focus of the research? Clinical Research

– What type of evidence was identified?

– What type of single subject design was used? Case Studies–Description of Two Events [not clear if the case part was retrospective or prospective; the investigators also collected normative data for comparison of acoustic measures (i.e., the Control group) ]

– What was the level of support associated with the type of evidence?
Level = C+

– Was phase of experimental condition concealed?
• from participants? No
• from assessors? No
• from data analyzers? Unclear

– Were the participants (Ps) adequately described? No

• How many Ps were involved in the study? 2 Ps who served in the case studies and a group (N = 13) of typical speakers served as controls for the acoustic measures.

CONTROLLED CHARACTERISTICS OF CASES:

• diagnosis: Primary Progressive Apraxia of Speech (PPAOS)

DESCRIBED CHARACTERISTICS OF CASES::

• age: (at beginning of study)
– Participant #1 (P1) = 53 years
– Participant #2 (P2) = 75 years

• gender:
– P1 = male
– P2 = female

• cognitive skills
– P1 = normal (at time1)
– P2 = normal (at time1)

• medications:
– P1 = antianxiety and antidespressant
– P2 = none listed

• time post onset at time1
– P1 = 5 years; 7.5 years
– P2 = 2 years; 4 years

CHARACTERISTICS OF CONTROLS FOR ACOUSTIC MEASURES

• number: 13
• gender: 7m; 6f
• age: 50 to 80 years (mean = 63.1)
• diagnoses:
– all free of dysarthria or AOS
– 4 no diagnosis of aphasia
– 4 had complaints regarding language but on testing were within normal limits for language and speech with normal neurological assessments
– 5 diagnosed with mild PPA

• Were the communication problems adequately described? Yes

• Disorder type(s): Primary progressive Apraxia of Speech (PPAOS)

– Was membership in treatment maintained throughout the study? Yes

• 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

– Did the design include appropriate controls? No, these were case studies that described performance at 2 time periods separated by 2 to 2.5 years.

• Were baseline data collected on all behaviors? No

– Were the outcome measures appropriate and meaningful? Yes

PROSODIC MEASURES

• MEASURE #1: Alternating Motion Rates (AMRs) duration/rate

• MEASURE #2: Sequential Motion Rates (SMRs) duration/rate

• MEASURE #3 : Duration of words and sentences

• MEASURE #4: Overall perception of prosody

• MEASURE #5: Pairwise Variability Index (PVI), a measure of equalized syllable stressing; scores close to 0 = equalized stress; ideal score is negative

NONPROSODIC MEASURES

• MEASURE #6: Overall score on the Apraxia of Speech Rating Scale in conversation (ASRS; range 0-64; 0 = no abnormality; Apraxia = 8; average score of people with PPAOS = 17)

• MEASURE #7: Severity rating of apraxia on a 5-point scale in conversation

• MEASURE #8: Severity rating of dysarthria on a 4-point scale in conversation

• MEASURE #9: Rating of functional speech severity on a 10-point scale in conversation (MSD Severity; 0 = nonvocal; 10 = normal speech)

• MEASURE #10: Alternating Motion Rates (AMRs)

• MEASURE #11: Articulation Error Score; error = (any one of the following) sound substitutions (distorted or undistorted; additions, repetitions; sound omissions, sound prolongations beyond those consistent with speech rate); false starts; any correction of sound error

• MEASURE #12: Rating on scale of nonverbal oral apraxia (maximum score = 32)

• MEASURE #13: Overall performance of the Western Aphasia Battery (WAB) Aphasic Quotient (AQ)

• MEASURE #14: Performance on a section of the WAB with 10 as the maximum score—Information Content

• MEASURE #15: Performance on a section of the WAB with 10 as the maximum score—Fluency

• MEASURE #16: Performance on a section of the WAB with 10 as the maximum score—Auditory Verbal Comprehension

• MEASURE #17: Performance on a section of the WAB with 10 as the maximum score—Repetition

• MEASURE #18: Performance on a section of the WAB with 10 as the maximum score—Naming

• MEASURE #19: Performance on the Writing Output portion of the WAB with a maximum score of 34

• MEASURE #20: Overall perception of articulation

• MEASURE #21: Performance on the Token Test

• MEASURE #22: Performance on the Boston Naming Test

• MEASURE #23: Neurological findings

§ List numbers of the outcomes that are subjective:

• MEASURE #1: Alternating Motion Rates (AMRs) duration

• MEASURE #2: Sequential Motion Rates (SMRs) duration

• MEASURE #3 : Duration of words and sentences

• MEASURE #4: Overall perception of prosody

• MEASURE #5: Pairwise Variability Index (PVI), a measure of equalized syllable stressing; scores close to 0 = equalized stress; ideal score is negative

§ List numbers of the outcomes that are objective:

• MEASURE #6: Overall score on the Apraxia of Speech Rating Scale in conversation (ASRS; range 0-64; 0 = no abnormality; Apraxia = 8; average score of people with PPAOS = 17)

• MEASURE #7: Severity rating of apraxia on a 5-point scale in conversation

• MEASURE #8: Severity rating of dysarthria on a 4-point scale in conversation

• MEASURE #9: Rating of functional speech severity on a 10-point scale in conversation (MSD Severity; 0 = nonvocal; 10 = normal speech)

• MEASURE #10: Alternating Motion Rates (AMRs)

• MEASURE #11: Articulation Error Score; error = (any one of the following) sound substitutions (distorted or undistorted; additions, repetitions; sound omissions, sound prolongations beyond those consistent with speech rate); false starts; any correction of sound error

• MEASURE #12: Rating on scale of nonverbal oral apraxia (maximum score = 32)

• MEASURE #13: Overall performance of the Western Aphasia Battery (WAB) Aphasic Quotient (AQ)

• MEASURE #14: Performance on a section of the WAB with 10 as the maximum score—Information Content

• MEASURE #15: Performance on a section of the WAB with 10 as the maximum score—Fluency

• MEASURE #16: Performance on a section of the WAB with 10 as the maximum score—Auditory Verbal Comprehension

• MEASURE #17: Performance on a section of the WAB with 10 as the maximum score—Repetition

• MEASURE #18: Performance on a section of the WAB with 10 as the maximum score—Naming

• MEASURE #19: Performance on the Writing Output portion of the WAB with a maximum score of 34

• MEASURE #20: Overall perception of articulation

• MEASURE #21: Performance on the Token Test

• MEASURE #22: Performance on the Boston Naming Test

• MEASURE #23: Neurological findings

§ Reliability data:

• The investigators explored the reliability of the acoustic measures and determined that the differences between 2 judges ranged from 0.3% to 5.8% (mean = <2%.)

• The investigators remeasured any measures that differed by more than 5%. This was considered to be a consensus measure.

8. Results:

• Did the target behavior(s) change over the course of the investigation? Yes, for the most part.

PROSODIC MEASURES

• MEASURE #1: Alternating Motion Rates (AMRs) duration/rate
– P1 = duration was slower than control group at time1; 33% slower at time2 than at time1

– P2 = time1 was slow; time2 remained slow

• MEASURE #2: : Sequential Motion Rates (SMRs) duration/rate
– P1 = during time1 duration was similar to Controls; 17% slower at time2 than at time1

– P2 = time1 was slow; time2 remained slow

• MEASURE #3 : Duration of words and sentences
– P1 = one word (of 4 words) was markedly slower than the control group during time1; slower at time2 compared to time1; sentence duration could not be measured because of false starts, hesitation, etc.

– P2 = time1 duration of individual words and words in sentences was longer than normal; time2 durations continued to be abnormal and were slower than time1

• MEASURE #4: Overall perception of prosody
– P1 = his prosody was more impaired (slower rate; syllable segmentation) was more evident) in time2

– P2 = time1 rate was slow with intersyllable and interword segmentation; time2 rate and segmentation were reported to be worse

• MEASURE #5: Pairwise Variability Index (PVI), a measure of equalized syllable stressing; scores close to 0 = equalized stress; ideal score is negative
– P1 = time1 = -54.2 which showed that syllable stressing was occurring but it was markedly smaller than the Controls (-90.5); time1 = -28.7 (abnormal)

– P2 = time1 = -27.5 syllable stressing was occurring but it was abnormally smaller than the Controls (-90.5); time2 = -42.2; this was still atypical but better

NONPROSODIC MEASURES

• MEASURE #6: Overall score on the Apraxia of Speech Rating Scale in conversation (ASRS; range 0-64; 0 = no abnormality; Apraxia = 8; average score of people with PPAOS = 17)
– P1 = time1 score was 21(abnormal); time2 score was 35

– P2 = time1 was 18 (abnormal) with most of the concerns related to rate and prosody; time2 score (21) was only ‘slightly worse” (p. 96)

• MEASURE #7: Severity rating of apraxia on a 5-point scale in conversation
– P1 = from time1 to time 2, his rating changed from 2 (moderate) to 4 (severe)

– P2 = time1 severity was 1 which represented mild apraxia; time2 severity = 2 (moderate apraxia)

• MEASURE #8: Severity rating of dysarthria on a 4-point scale in conversation
– P1 = time1 no sign of dysarthria; time2 diagnosis of spastic dysarthria was equivocal

– P2 = time1 no sign of dysarthria; time2 diagnosis of spastic dysarthria was equivocal

• MEASURE #9: Rating of functional speech severity on a 10-point scale in conversation (MSD Severity; 0 = nonvocal; 10 = normal speech)
– P1 = from time1 to time 2, his rating changed from 6 (sometimes has to repeat messages to 3 (only 1 word responses were intelligible)

– P2 = time1 rating was 7 (impaired but understood); time2 the rating fell to 6 (repetitions occasionally required)

• MEASURE #10: Alternating Motion Rates (AMRs)
– P1 = no articulatory errors with the exception of mild distortions (time1); time2 speech sounds were off-target regarding place or manner; prolongations were noted
– P2 = time1 and time2 only mild distortions were noted

• MEASURE #11: Articulation Error Score; error = (any one of the following) sound substitutions (distorted or undistorted; additions, repetitions; sound omissions, sound prolongations beyond those consistent with speech rate); false starts; any correction of sound error
– P1 = from 52% at time1 to 63% at time2; both times he exhibited the following
§ distortions
§ articulatory groping
§ repetitions
§ prolongations
§ false starts
§ omissions
§ additions

– P2 = time1 score was 7%; time2 the score was 13%, she produced
§ omission
§ false starts

• MEASURE #12: Rating on scale of nonverbal oral apraxia (maximum score = 32)
– P1 = from time1 (24 mild impairment) to time2 to a score of 5.

– P2 = time1 rated as moderately impaired (14); time3 was rated as 12

• MEASURE #13: Overall performance of the Western Aphasia Battery (WAB) Aphasic Quotient (AQ)
– P1 = from time1 to time2, his score had fallen to mild-moderate impairment from normal

– P2 = time1 score was slightly below the normal cutoff (93.3); time2 = 93.4

• MEASURE #14: Performance on a section of the WAB with 10 as the maximum score—Information Content
– P1 = from time1 (10) to time2 (8) there was some change

– P2 = from time1 (10) to time2 (10) there was no change

• MEASURE #15: Performance on a section of the WAB with 10 as the maximum score—Fluency
– P1 = at time2 (4)he exhibited mild agrammatism as evidenced in reduced fluency problems; this was not observed at time1 (9)

– P2 = from time1 (10) to time2 (9) there was slight change

• MEASURE #16: Performance on a section of the WAB with 10 as the maximum score—Auditory Verbal Comprehension
– P1 = at time2 he exhibited mild confrontation naming problems; this was not observed at time1 but the scores for both were 10

– P2 = from time1 (9.45) to time2 (9.8) there was slight improvement

• MEASURE #17: Performance on a section of the WAB with 10 as the maximum score—Repetition
– P1 = from time1 (9.3) to time2 (8.6) there was some change

– P2 = from time1 (9.1) to time2 (8.9) there was slight change

• MEASURE #18: Performance on a section of the WAB with 10 as the maximum score—Naming
– P1 = at time2 (9.4) he exhibited mild confrontation naming problems; this was not observed at time1 (10)

– P2 = performance at time1 (9.1) was characterized as ‘somewhat reduced’ (p. 96); time2 (8.9) there was a slight change

• MEASURE #19: Performance on the Writing Output portion of the WAB with a maximu score of 34
– P1 = the scores in time1 (33.5) and time2 (32) were similar and normal

– P2 = time1 (34) was normal; time2 score (18) was low but investigators suggested this was due to motoric problems.

• MEASURE #20: Overall perception of articulation
– P1 = from time1 to time 2 speech sound errors were more evident

– P2 = at time1 mild distortions were noted as well as a few false starts and prolongations; time2 performance suggested mild deterioration

• MEASURE #21: Performance on the Token Test
– P1 = time1 (22) and time2 (19) was normal

– P2 = time1 (20) and time2 (20) was normal

• MEASURE #22: Performance on the Boston Naming Test
– P1 = time1 the score was 12 (borderline abnormal); time2 the score had decreased to 10

– P2 = time1 (15) was normal; time2 (12) “borderline abnormal” (p. 96); the investigators claimed this was indicative of aphasia

• MEASURE #23: Neurological findings
– P1 = time1
§ no evidence of neurodegenerative diseases
§ only concerns were reduced left arm swing and slow alternating finger movement (left hand)
§ Mini-Mental State Examination (MMSE) was normal
§ Flurodeoxglucose-positron emission tomography (FDG-PET) showed subtle problems in supplementary motor area, posterior lateral frontal lobes, caudate nucleus
§ Magnetic Resonance Imaging (MRI) showed atrophy in posterior lateral frontal lobes and insula and the supplementary motor area
– P1 = time2
§ MMSE = normal
§ FDG-PET and MRI progression of time1 problem; progressive brain atrophy greater than that in the Control group but with the reported range for Ps with PPAOS.

– P2 = time1
§ MMSE was normal
§ diagnosis of mild parkinsonism and ideational apraxia
§ FDG-PET = hypometabolism of
¶ posterior lateral frontal lobe
¶ supplementary motor area
¶ caudate nucleus
¶ midbrain
§ MRI atrophy was noted in
¶ supplementary motor area
¶ caudate nucleus
¶ putmen
¶ midbrain

– P2 = time2
§ neurological condition had deteriorated
§ diagnoses included mild parkinsonism, progress supranuclear palsy syndrome, and corticobasal syndrome
§ MMSE – normal
§ FDG-PET – progression of hypometabolism
§ MRI – overall progression of atrophy

– Description of baseline:

• Were baseline data provided? No

– What is the clinical significance? NA

– Was information about treatment fidelity adequate? NA

– Were maintenance data reported? NA

– Were generalization data reported? NA

– Brief description of the design:

• The investigators assessed the speech, language, and neurological skills of two Ps who had been diagnosed with PPAOS.
• It was not clear whether this was a progressive or retrospective design.
• Both Ps were tested 2 times:
– The first testing time was several years (5 years or 2 years) post onset.
– The second testing time was 2 to 2.5 years after the first session.
• The outcomes included acoustic and perceptual of speech and language as well as the results of neurological assessments.
• The of outcomes were descriptively compared from time1 to time2.
• In addition, to aid in the interpretation of the acoustic measures a group of AOS free speakers served as a Control Group .

ASSIGNED OVERALL GRADE OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: NA, this investigation was not concerned with intervention.

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