EBP THERAPY ANALYSIS
Note: Scroll about two-thirds of the way down the page to read the summary of the procedures.
C = Clinician
dB = decibel
EBP = evidence-based practice
ETA = Partial Eta Squared
f = female
F0 = Fundamental Frequency
ICC) = Intraclass Correlation Coefficient
ITV = Intensive Voice Therapy
LMRVT = Lessac-Madsen resonant voice therapy program
MPT = Maximum phonation time
NA = not applicable
P = Patient or Participant
PCA = Percent Close Agreement
PEA = Percent Exact Agreement
pmh = Patricia Hargrove, blog developer
RCT = randomized clinical trial
SLP = speech–language pathologist
TVT = Traditional Voice Therapy
VFE = Abbott’s Lessac-Madsen resonant voice therapy program (LMRVT) and Stemple’s vocal function exercises (VFE.)
WNL = within normal limits
SOURCE: Fu, S., Theodoros, D. G., & Ward, E. C. (2015). Intensive versus traditional voice therapy for vocal nodules: Perceptual, physiological, acoustic, and aerodynamic changes. Journal of Voice, 29 (2), 260.e31-260.e44.
DATE: September 6, 2017
ASSIGNED GRADE FOR OVERALL QUALITY: B (The highest possible grade, based on the design of the investigation is B+ because it is classified as Prospective, Nonrandomized Group Design with Controls. This grade reflects the quality of the evidence of the treatment and is not a judgment regarding the worth of the treatment.)
TAKE AWAY: This investigation compared 2 treatment groups (intensive voice therapy , ITV, versus traditional voice therapy, TVT) analyzing treatment outcomes that included perceptual, physiological, acoustic, and aerodynamic measures. Only 3 outcomes (duration, pitch and intensity) could be considered prosodic and they are the focus of this review. Treatment consisted of 2 phases: a brief course of vocal hygiene followed by 8 sessions of therapy administered over a 3 week period (ITV) or an 8 week period (TVT.) Overall, physiological outcomes improved following vocal hygiene and physiological, perceptual, and acoustic outcomes improved following both of the ITV and TVT. With respect to prosodic outcomes, pitch and intensity also improved following either treatment. There difference between ITV and TVT treatments were not significant.
- What type of evidence was identified?
- What was the type of evidence? Prospective, Nonrandomized Group Design with Controls
- What was the level of support associated with the type of evidence?
Level = B+
- Group membership determination:
- If there was more than one group, were participants (Ps) randomly assigned to groups? No, the investigators labeled this as a “pragmatic” RCT because participants (Ps) were assigned based on their availability.
- If there were groups and Ps were not randomly assigned to groups, were members of groups carefully matched? Yes. The assignment strategy included
– Ps were matched in pairs based on age, occupation, and severity.
– The investigators assigned Ps to treatment groups based on availability for treatment
- Was administration of intervention status concealed?
- from participants? No
- from clinicians? No
- from analyzers? Yes
- Were the groups adequately described? Yes
- How many Ps were involved in the study?
– total # of Ps: 53
– # of groups: 2
– Names of groups and the # of participants in each group:
– Traditional Voice Therapy (TVT) = 29
– Intensive Voice Therapy (ITV) = 24
- age: 18 to 55 years
- gender: f
- medical history: excluded if there was a history of “allergies, lung disease, or other concomitant vocal pathology” (p. 260.e32)
- communication skills: articulation, resonance, language skills were within normal limits (WNL)
- prescription medicine: those associated with changes in laryngeal function, mucosa, or muscle activity” (p. 260.e32) were excluded
- previous voice therapy or laryngeal surgical intervention: none
- history of singing or speaking training: none
- diagnosis: bilateral vocal nodules
- hearing: WNL
- comorbid psychiatric or neurologic status: WNL
- age (mean):
TVT = 37.52
ITV = 37.54
- number :
TVT = 29
ITV = 24
– mild = 2
– mild-moderate = 19
– moderate = 7
– moderate-severe = 1
– mild = 0
– mild-moderate = 12
– moderate = 12
– moderate-severe = 0
– professional voice user = 16
– nonprofessional voice user = 13
– professional voice user = 14
– nonprofessional voice user = 10
- language spoken: Mandarin (all Ps were from Taiwan)
- Were the groups similar before intervention began? Yes
- Were the communication problems adequately described? Yes _x__ No
– disorder type: bilateral vocal nodules
– functional level: severity level ranged from mild to moderate-severe
- Was membership in groups maintained throughout the study?
- Did each of the groups maintain at least 80% of their original members? No
– 31 Ps were originally assigned to IVT: 7 withdrew, therefore 77% (24/31) remained
– 37 Ps were originally assigned to IVT: 8 withdrew , therefore 78% (29/37) remained
- Were data from outliers removed from the study? No
- 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 foil/comparison and the target groups constant? Yes but the TVT group had more homework.
- Were the outcomes measure appropriate and meaningful? Yes
NOTE: There were multiple perceptual, physiological, acoustic, and aerodynamic outcomes. Only the prosody related outcomes are summarized here.
- OUTCOME #1: Maximum phonation time (MPT, a measure of duration)
- OUTCOME #2: Fundamental Frequency (F0)
- OUTCOME #3: Intensity of prolonged /a/ (in dB)
- OUTCOME #4: Intensity of conversation (in dB)
– NONE of the outcome measures were subjective.
– All of the outcome measures were objective.
- Were reliability measures provided?
NOTE: Data presented for this question are combined 2 of major categories of outcomes. Neither of these 2 major categories included the prosodic outcomes of this review. Nevertheless, they are presented as indicators of reliability.
- Interobserver for analyzers? Yes
- Perceptual Ratings:
∞ Intraclass Correlation Coefficient (ICC) = 0.64 (“Substantial Agreement”, p. 260.e33)
∞ Percent Exact Agreement (PEA) = 74%
∞ Percent Close Agreement (PCA) = 93%
- Physiological Ratings:
∞ ICC = 0.88 (“almost perfect”, p. 260.e34)
∞ PEA = 74%
∞ PCA = 99.6%
- Intraobserver for analyzers? Yes
- Perceptual Ratings:
∞ Intraclass Correlation Coefficient (ICC) = 0.85 (“almost perfect” p. 260.e330
∞ Percent Exact Agreement (PEA) = 71%
∞ Percent Close Agreement (PCA) = 99%
- Physiological Ratings:
∞ ICC = 0.91 (“almost perfect”, p. 260.e34)
∞ PEA = 91.5%
∞ PCA = 97.4%
- Treatment fidelity for clinicians? No
- What were the results of the statistical (inferential) testing and/or the description of the results?
SUMMARY OF RESULTS
TREATMENT AND COMPARISON TREATMENT GROUP ANALYSES
- OUTCOME #1: Maximum phonation time (MPT, a measure of duration): no significant differences for treatment groups, interactions, or main effects
- OUTCOME #2: Fundamental Frequency (F0): significant main effect for times eta = 0.707; differences for interaction and between group comparisons were not significant
- OUTCOME #3: Intensity of prolonged /a/ (in dB): significant main effect for times eta = 0.293; differences for interaction and between group comparisons were not significant
- OUTCOME #4: Intensity of conversation (in dB): no significant differences for treatment groups, interactions, or main effects
– The following statistical test were used to determine significance:
- Mann-Whitney U
- Chi Square
– Were confidence interval (CI) provided? No
- What is the clinical significance?
– Measure used: Partial Eta Squared (ETA)
– Results of EBP testing and the interpretation: ONLY DATA FOR PROSODIC OUTCOMES WITH SIGNIFICANT DIFFERENCES ARE REPORTED HERE
- OUTCOME #2: Fundamental Frequency (F0): significant main effect for times eta = 0.707 (large effect)
- OUTCOME #3: Intensity of prolonged /a/ (in dB) ): significant main effect for times eta = 0.293 (moderate effect)
- Were maintenance data reported? No
- Were generalization data reported? No
- Describe briefly the experimental design of the investigation.
- Ps were matched in pairs based on age, occupation, and severity.
- The investigators assigned Ps to treatment groups based on availability for treatment.
- The Ps were subjected to testing three times:
– Before the first phase of treatment (Vocal Hygiene)
– Before the 2nd phase of treatment which was 3 weeks following the completion of vocal hygiene treatment
– Following the completion of ITV or TVT.
- ITV and TVT involved identical treatment protocols. Only the intensity of the treatments varied:
– for ITV, the 8 sessions were administered over a 3 week period
- 3 sessions Week1
- 2 sessions Week2
- 3 sessions Week3
– for TVT, the 8 sessions were administered once a week for 8 weeks.
- There were 4 categories of outcomes (only prosodic outcomes are reported in this review):
– Auditory perceptual
– Physiological ratings (videostroboscopic assessment)
– Aerodynamic assessment (Outcome 1 was elicited here)
– Acoustic assessment (Outcomes2, 3, and 4 were elicited here)
ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: B
SUMMARY OF INTERVENTION
PURPOSE: to investigate whether the intensity of treatment affects outcomes
POPULATION: Voice problems, Vocal nodules; Adults
MODALITY TARGETED: production
ELEMENTS/FUNCTIONS OF PROSODY TARGETED: duration, pitch, intensity
OTHER TARGETS: voice quality, vocal fold physiology (i.e., videostroboscopic assessment), aerodynamic measures (other than duration), acoustic characteristics (other than pitch and intensity)
DOSAGE: For the most part, the dosage for both treatment groups was identical although the schedule differed. The Ps were assigned homework and since the TVT lasted for a longer period of time, they acquired more minutes of homework.
- Phase 1 (vocal hygiene) – 1 session
- Phase 2 (direct treatment) – 8 sessions commencing 3 weeks after Phase 1; each session was 45 minutes in duration
- IVT = 8 sessions within 3 weeks (Week 1 = 3 sessions; Week 2 = 2 sessions; Week 3 = 3 sessions)
- TVT = 8 sessions administered once a week for 8 weeks
ADMINISTRATOR: SLP (Principle Investigator)
- The 2 treatments (ITV and TVT) were identical. They differed only in the intensity of treatment.
- The treatment was derived from Verdolini Abbott’s Lessac-Madsen resonant voice therapy program (LMRVT) and Stemple’s vocal function exercises (VFE.) The administrator was a certified LMRVT provider.
- The treatment comprised 2 phases:
– Phase 1 = Vocal Hygiene
– Phase 2 = Direct therapy derived from LMRVT and VFE
- This phase involved 1 session in which the Clinician (C) described the principles of healthy voice use and asked the P to follow the principles.
- Sessions began with muscle relaxation exercises for the face, neck, and shoulders.
- C worked with P to practice a good voice quality using a forward focus when producing exercises for stretch (ascending pitch glide) and contraction (descending pitch glide.) Target words were knoll, whoop, and boom.
- Therapy progressed through a hierarchy of targets:
– sounds in isolation
– naturalistic activities outside the clinic
- Ps were assigned homework (using worksheets) which consisted of practicing for 15 minutes, 2 times a day on nontherapy days and 1 time a day, on therapy days.