Connaghan & Patel (2013)

September 20, 2019

 

ANALYSIS GUIDELINES

Comparison Research

 KEY:

eta =  partial eta squared

f =  female

GFTA-2 =  Goldman-Fristoe Test of Articulation-2

HC =  healthy controls

m =  male

MLU =  mean length of utterance

MSI =  motor speech impairment

NA =  Not Applicable

P =  participant or patient

pmh =  Patricia Hargrove, blog developer

SLP =  speech-language pathologist

WNL =  within normal limits

  

SOURCE:   Connaghan, K. P., &  Patel, R. (2013).  Impact of prosodic strategies on vowel intelligibility in childhood motor speech impairment.  Journal of Medical Speech-Language Pathology, 20 , 133-139.

 

REVIEWER(S): pmh

 

DATE:September 20, 2019

 

ASSIGNED GRADE FOR OVERALL QUALITY:   No grade assigned. This investigation compared performance of children on 4 tasks and is not considered to be interventional research. However, its findings have implications for intervention.

 

TAKE AWAY: This preliminary investigation explored the vowel production of children with motor speech impairment (MSI) and healthy controls in 4 conditions. Two of the 3 members of the MSI group were perceived to improve vowel intelligibility in at least one of the conditions. In addition, acoustic analysis revealed that participants (Ps) with MSI displayed significantly more F2 variance than the Healthy Control (HC) group.

 

  1. What type of evidence was identified?

                                                                                                             

  • What was the type of design? Comparison Research and Prospective, Nonrandomized Group Design with Controls
  • What was the focus of the research? Clinically Related

           

  1. Group membership determination:

                                                                                                           

  • If there were groups, were Ps randomly assigned to groups? No, the groups were children with motor speech impairment (MSI) and healthy controls (HC); therefore, assignment cannot be random.

 

  • If there were groups and Ps were not randomly assigned to groups, were members of groups carefully matched?Not Applicable (NA)

 

  1. Were experimental conditions concealed?
  • from participants? No
  • from administrators of experimental conditions? No
  • from analyzers/judges?No

 

  1. Were the groups adequately described? Yes

–   How many participants were involved in the study?

  • total # of Ps: 6
  • # of groups:  2
  • List names of groups and the number of Ps in each group:

–  motor speech impairment (MSI) =  3

–  healthy controls (HC) =  3

  • Did all groups maintain membership throughout the investigation? Yes

 

–  CONTROLLED CHARACTERISTICS                                                  

  • age:

     –  HC within 6 months of age of an MSI participant (P)

  • diagnosis:

     –  MSI:  childhood apraxia of speech

     –  HC: free from reported or suspected communication or developmental impairments

 

–  DESCRIBED CHARACTERISTICS

  • age:

     –  MSI:  3;6 to 8;5

     –  HC: 4;1 to 8;10

  • gender:

     –  MSI:   3m

     –  HC:  1m, 2f

  • cognitive skills:

     –  MSI:  developmental delay (1P)

     –  HC:  all within normal limits (WNL)

  • expressive language:

     –  MSI:  expressive language delay (1P)

     –  HC:  all WNL

  • receptive language:

     –  MSI:  receptive language delay (1P)

     –  HC:  all WNL

  • phonology:

     –  MSI:  phonological disorder (1P)

     –  HC:  all WNL

  • Motor skills

     –  MSI:  generalized motor planning impairment (2P)

     –  HC:  all WNL

  • Hearing:

 

–  Were the groups similar?  Yes

                                                         

–  Were the communication problems adequately described?  Yes

  • disorder type: motor speech impairment; CAS
  • Other characteristics (Table 1; p. 134)

–  MSI#1:

∞  vowel and Consonant Inventory: Limited

∞  vowel distortions

∞  sequencing difficulties (verbal)

∞  inconsistent errors

∞  below 1%ile on the Goldman-Fristoe Test of Articulation-2 (GFTA-2)

∞  oral structure/function WNL

–  MSI #2:

∞  speech sound distortions

∞  idiosyncratic speech sound substitutions

∞  sequencing difficulties (verbal and nonverbal)

∞  phonological impairment

∞  10th%ile on the GFTA

–  MSI #3:

∞  slow speech rate

∞  inconsistent speech sound errors

∞  speech sound distortions

∞  sequencing difficulties (verbal and nonverbal)

∞  18th% on the GFTA

 

  1. What were the different conditions for this research?
  • Subject (Classification) Groups? No 
  • Experimental Conditions? Yes

–  Habitual speech

–  Increased loudness

–  Slowed rate

–  Empathic stress

  • Criterion/Descriptive Conditions?No 

 

  1. Were the groups controlled acceptably?  NA

 

  1. Were dependent measures appropriate and meaningful? Yes
  • OUTCOME #1:Vowel acoustics (F1 and F2 on the vowel nucleus)
  • OUTCOME #2:Intelligibility

 

–  The dependent measure that is subjective is OUTCOME #2:  Intelligibility

–  The dependent measures that is objective is OUTCOME #1:  Vowel acoustics (F1 and F2 on the vowel nucleus)

 

  1. Were reliability measures provided?

–  Interobserver for analyzers?  Yes

  • OUTCOME #1:  Vowel acoustics (r = 0.92)

  Intraobserver for analyzers?  No 

 Treatment or test administration fidelity for investigators?  No 

 

  1. Description ofdesign:
  • Three children with CAS (MSI group) and 3 typically developing peers (HC group) participated.

 

  • The stimuli were 6 sentences that were modeled for the Ps in 4 conditions:

–  Habitual speech

–  Increased loudness

–  Slowed rate

–  Empathic stress

Therefore, there were a total of 24 stimuli.

 

  • Following a training procedure, each P imitated the 24 sentences (6 sentences, 4 times each) after hearing and viewing a visual representation of each sentence (i.e., the audio-visualization techniques).

 

  • The investigators recorded the Ps productions. To measure vowel accuracy, the investigators plotted F1 and F2 for the vowels /i/, /a/, and /u/ from each of the 24 sentences for a target of 48 vowels productions per P.(NOTE:  2 of the Ps, one from each group, failed to meet the criterion for increased loudness and that data could not be analyzed statistically.)

 

  • To measure intelligibility and stress placement, the investigators enlisted 16 SLP students to serve as listeners.

 

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

 

  • OUTCOME #1:Vowel acoustics (F1 and F2 on the vowel nucleus)

∞  the coefficient of variation (COV) for F1 was significantly higher for the MSI group

 

  • OUTCOME #2:Intelligibility

∞  2 of the 3 MSI Ps increased in intelligibility relative to the habitual condition using at least one of the 3 strategies (loud, slow, emphatic stress.)  NOTE: this analysis was descriptive only.

 

–  What was the statistical test used to determine significance ANOVA

–  Were effect sizes provided?  No

  Were confidence interval (CI) provided?  No

 

  1. Summary of correlational results:  NA

 

  1. Summary of descriptive results: Qualitative research  NA

 

  1. Brief summary of clinically relevant results:
  • The performance of the 3 MSI Ps varied with intelligibility and production of vowel.
  • Ps with MSI exhibited more variability in F2 than HC peers.

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  No Grade

 

============================================================

 


Lu et al. (2013)

September 7, 2019

 

EBP THERAPY ANALYSIS for

Single Case Designs

 NOTE: 

  • The summary of the intervention procedure can be viewed by scrolling about 80% of the way down on this page.

Key:

C =  Clinician

EBP =  evidence-based practice

f =  female

GGS = glottal gap size

LSVT =  Lee Silverman Voice Treatment

m = male

NA  = not applicable

P =  Patient or Participant

Pmh =  Patricia Hargrove, blog developer

SLP =  speech–language pathologist

SPI =  soft phonation index

 

SOURCE:  Lu, F-L. Presley, S., & Lammers, B. (2013). Efficacy of intensive phonatory-respiratory treatment (LSVT) for presbyphonia: Two case reports. Journal of Voice, 27 (6), 786.e11 – 786.e23.

 

REVIEWER(S):  pmh

 

DATE: September 1, 2019

 

ASSIGNED OVERALL GRADE:  The highest possible grade, based on the design of the investigation (Single Case Design) is C+. This grade represents the design quality of the investigation and is not meant to be a judgment about the quality of the intervention.

 

TAKE AWAY: Single case studies were used to explore the efficacy of Lee Silverman Voice Treatment (LSVT) for improving voice quality of 2 patients with vocal fold atrophy and bowing that accompanied with aging (i.e., presbyphonia). The investigation revealed significant and/or marked improvement in almost all of the laryngeal configuration, glottal gap, phonatory function, acoustic correlates of vocal fold adduction/voicing qualities, and perceptual aspects of voice quality outcomes.

 

  1. What was the focus of the research? Clinical

 

 

  1. What type of evidence was identified?

What type of single subject design was used?  Case Studies:  Description with Pre and Post Test Results (Prospective, Nonrandomized)

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

                                                                                                           

 

  1. Was treatment concealed?
  • from participants?No
  • from clinicians? No
  • from data analyzers? Unclear

 

 

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

–  How many Ps were involved in the study?  2

–  What P characteristics/variables were controlled or described?

CONTROLLED CHARACTERISTIC:

  • diagnosis: Presbylaryngis      

DESCRIBED CHARACTERISTICS:

  • age:

∞  Subject 1: 62 years

∞  Subject 2: 88 years

  • gender:

∞  Subject 1:  f

∞  Subject 2: m                          

  • profession

∞  Subject 1: retired office worker

∞  Subject 2: retired professor of vocal studies               

  • medical history:

∞  Subject 1:

  • asthma (for 6 years)
  • allergies (airborne; since young adulthood)
  • sinus (year round; since young adulthood)
  • suspected gastroesophageal reflux

∞  Subject 2:

  • suspected gastroesophageal reflux

                                                 

–  Were the communication problems adequately described? Yes

–  List the disorder type:  Presbylaryngis

–  List other aspects of communication that were described:

  •      Subject 1:

          ∞ In long conversations, her voice quality became weak and breathy.

∞  On the telephone, listeners had moderate difficulty hearing her.

  • Subject 2:

          ∞ in conversation

  • weak and breathy voice
  • trouble being heard

∞  Voice problems started about 5 years prior to the investigation. Voice quality has slowly declined.

                                                                                                                       

  1. 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

 

 

  1. Did the design include appropriate controls? No, it was a case study.

                                                                       ,

  • Were baseline/preintervention data collected on all behaviors?Yes
  • Did probes/intervention data include untrained stimuli?Yes
  • Did probes/intervention data include trained stimuli?Yes
  • Was the data collection continuous? Yes, for some of the outcomes.
  • Were different treatment counterbalanced or randomized?NA

 

 

  1. Were the outcome measures appropriate and meaningful? Yes

 

LARYNGEAL CONFIGURATION (STROBOLARYNGOSCOPIC) OUTCOMES

  • OUTCOME #1: General vocal health before and after intervention
  • OUTCOME #2:Severity of vocal fold atrophy and bowing before and after intervention
  • OUTCOME #3: Glottal closure/Glottal Gap Size (GGS) before and after intervention
  • OUTCOME #4: Vibratory pattern of the vocal folds before and after intervention

 

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)
  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)
  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #9: Maximum phonation time (before and after intervention and during 16 treatment sessions)
  • OUTCOME #10: Highest pitch (before and after intervention)
  • OUTCOME #11:Lowest pitch (before and after intervention)
  • OUTCOME #12: Pitch range (before and after intervention)

 

ACOUSTIC MEASUREMENTS

  • OUTCOME #13: Fundamental frequency (F0) in Hz pre and post intervention
  • OUTCOME #14:F0 standard deviation in Hz pre and post intervention
  • OUTCOME #15:Perturbation as measured by jitter (%) pre and post intervention
  • OUTCOME #16: Perturbation as measured by shimmer (in dB) pre and post intervention
  • OUTCOME #17:Noise as measured by harmonic-to-noise ratio pre and post intervention
  • OUTCOME #18: Noise as measured by soft phonation index (SPI) pre and post intervention
  • OUTCOME #19: Voice breaks: Degree of voice breaks (%) pre and post intervention
  • OUTCOME #20:Voice breaks:  Number  of voice breaks pre and post intervention
  • OUTCOME #21: Voice irregularity: Degree of voiceless segments (%) pre and post intervention
  • OUTCOME #22: Voice irregularity: Number of voiceless segments pre and post intervention

 

AUDITORY PERCEPTUAL JUDGMENT OUTCOMES

  • OUTCOME #23: Description of voice quality before and after treatment
  • OUTCOME #24:Rating on GRBAS scale (0= normal; 3 = extremely deviant)

 

–  Outcomes that are subjective:

 

LARYNGEAL CONFIGURATION (STROBOLARYNGOSCOPIC) OUTCOMES

  • OUTCOME #1: General vocal health
  • OUTCOME #2:Severity of vocal fold atrophy and bowing
  • OUTCOME #3: Glottal closure/Glottal Gap Size (GGS)
  • OUTCOME #4: Vibratory pattern of the vocal folds

 

AUDITORY PERCEPTUAL JUDGMENT OUTCOMES

  • OUTCOME #13: Description of voice quality before and after treatment
  • OUTCOME #14:Rating on GRBAS scale (0= normal; 3 = extremely deviant) before and after intervention

                                                                                       

–  Outcomes that are objective:

 

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)
  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)
  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)
  • OUTCOME #9: Maximum phonation time (before and after intervention and during 16 treatment sessions)
  • OUTCOME #10: Highest pitch (before and after intervention)
  • OUTCOME #11:Lowest pitch (before and after intervention)
  • OUTCOME #12: Pitch range (before and after intervention)

 

ACOUSTIC MEASUREMENTS

  • OUTCOME #13: Fundamental frequency (F0) in Hz pre and post intervention
  • OUTCOME #14:F0 standard deviation in Hz pre and post intervention
  • OUTCOME #15:Perturbation as measured by jitter (%) pre and post intervention
  • OUTCOME #16: Perturbation as measured by shimmer (in dB) pre and post intervention
  • OUTCOME #17:Noise as measured by harmonic-to-noise ratio pre and post intervention
  • OUTCOME #18: Noise as measured by soft phonation index (SPI) pre and post intervention
  • OUTCOME #19: Voice breaks: Degree of voice breaks (%) pre and post intervention
  • OUTCOME #20:Voice breaks:  Number of voice breaks pre and post intervention
  • OUTCOME #21: Voice irregularity: Degree of voiceless segments (%) pre and post intervention
  • OUTCOME #22: Voice irregularity: Number of voiceless segments pre and post intervention

 

– RELIABILITY DATA: No reliability data were provided.

 

 

  1. Results:

–  Did the target behaviors improve when treated?  Yes, for the most part

 

LARYNGEAL CONFIGURATION (STROBOLARYNGOSCOPIC) OUTCOMES

  • OUTCOME #1: General vocal health (description of changes from pre to post intervention)

–  Subjects 1 and:  color of vocal folds improved

 

  • OUTCOME #2:Severity of vocal fold atrophy and bowing (description of changes from pre to post intervention)

–  Subjects 1 and 2 :  concavity of edges of the vocal folds was reduced following intervention

 

  • OUTCOME #3: Glottal closure/Glottal Gap Size (GGS) (description of changes from pre to post intervention)

–  Subjects 1 and 2:  size of GGS reduced from small /moderate to minute anterior slit or complete or near complete closure; normalized GGS significantly smaller post treatment

 

  • OUTCOME #4: Vibratory pattern of the vocal folds (description of changes from pre to post intervention)

–  Subjects 1 and 2: improved from moderate deviance to normal/near normal

 

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3

 

  • OUTCOME #9: Maximum phonation time (MPT, before and after intervention and during 16 treatment sessions)

–  Subject 1:  significant increase from pre to post intervention with steady improvement over the course of therapy

–  Subject 2:  significant increase over the course of treatment but the pre intervention was abnormally long and; therefore, there was no significant difference from pre to post intervention

 

  • OUTCOME #10: Highest pitch (before and after intervention)

–  Subjects 1 and 2:  significantly higher

 

  • OUTCOME #11:Lowest pitch (before and after intervention)

–  Subject 1:  significantly higher

–  Subject 2:  no significant difference

 

  • OUTCOME #12: Pitch range (before and after intervention)

–  Subjects 1 and 2: significantly wider

 

ACOUSTIC MEASUREMENTS  (these differences were only described; no inferential statistical analysis

  • OUTCOME #13: Fundamental frequency (F0) in Hz pre and post intervention

–  Subject 1:  improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #14:F0 standard deviation in Hz pre and post intervention

–  Subject 1:  improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #15:Perturbation as measured by jitter (%) pre and post intervention

–  Subject 1: improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #16: Perturbation as measured by shimmer (in dB) pre and post intervention

–  Subject 1:  improved

–  Subject 2:  pre was close to normal for pre so there was only limited change

 

  • OUTCOME #17:Noise as measured by harmonic-to-noise ratio pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #18: Noise as measured by soft phonation index (SPI) pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #19: Voice breaks: Degree of voice breaks (%) pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #20:Voice breaks:  Number  of voice breaks pre and post intervention

–  Subjects 1 and 2:  lowered after treatment

 

  • OUTCOME #21: Voice irregularity: Degree of voiceless segments (%) pre and post intervention

–  Subjects 1 and :  lowered after treatment

 

  • OUTCOME #22: Voice irregularity: Number of voiceless segments pre and post intervention

–  Subject 1 and:  lowered after treatment

 

AUDITORY PERCEPTUAL JUDGMENT OUTCOMES

  • OUTCOME #23: Description of voice quality before and after treatment

– Subject 1:

∞  preintervention described as hoarse, weak, shortened phrasing

∞  postintervention describes as normal with trace of breathiness

– Subject 2:

∞  preintervention described as hoarse, breathy, weak, slightly shaky

 

  • OUTCOME #24: Rating on GRBAS scale (0= normal; 3 = extremely deviant) before and after intervention

 

Subject 1

Pre                            Post

–  Grade =                               2                                1

–  Roughness =                     1                                 0

–  Breathiness =                    2                                1

–  Asthenia =                          2                                0

–  Strain =                               0                                0

 

Subject 2

Pre                            Post

–  Grade =                               2                                1

–  Roughness =                     2                                1

–  Breathiness =                    2                                1

–  Asthenia =                          2                                0

–  Strain =                               0                                0

 

 

  1. Description of baseline:

 

9a  Were baseline data provided?  Variable, the following outcomes were measured during each treatment session:

                       

PHONATORY FUNCTION OUTCOMES

  • OUTCOME #5:Intensity of sustained /a/  (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3  (marked improvement)

 

  • OUTCOME #6:Intensity of functional speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3 (moderate improvement)

 

  • OUTCOME #7: Intensity in oral reading task (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3  (moderate improvement)

 

  • OUTCOME #8:Intensity in running speech (before and after intervention and during 16 treatment sessions)

–  Subject 1 and 2: significantly louder from pre to post intervention; rise in sound pressure level noted after session 3 (marked improvement)

 

  • OUTCOME #9: Maximum phonation time (MPT, before and after intervention and during 16 treatment sessions)

–  Subject 1:  significant increase from pre to post intervention with steady improvement over the course of therapy (marked improvement)

–  Subject 2:  significant increase over the course of treatment but the pre intervention was abnormally long and; therefore, there was no significant difference from pre to post intervention  (limited improvement)

 

–  Was baseline low (or high, as appropriate) and stable?  Generally the baselines were low and stable.

                                                       

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

 

 

  1. What is the clinical significance(List outcome number with data with the appropriate Evidence Based Practice, EBP, measure.) NA, magnitude of effect was not provided.

 

  1. Was information about treatment fidelity adequate?Not Provided

 

 

  1. Were maintenance data reported? No. However,when direct treatment was terminated, Ps were expected to complete daily practice routines to ensure maintenance. Maintenance, however, was not targeted as an outcome in this investigation.

 

 

  1. Were generalization data reported?Yes.Since improved loudness is considered the focus of LSVT, any outcome not targeting loudness/intensity can be considered generalization.

 

 

  1. Brief description of the design:

 

  • Two adults who had been diagnosed with presbyphonia (age related vocal fold atrophy and bowing) were Ps in this investigation (design: nonrandomized, prospective case study.)

 

  • Each of the Ps received 4 weeks of LSVT from SLPs who also were certified by LSVT.

 

  • For all the outcomes, the investigators administered pre and post intervention measures of laryngeal configuration, glottal gap, phonatory function, acoustic correlated of vocal fold adduction/voicing qualities, and perceptual aspects of voice quality.

 

  • For several of the outcomes, the investigators also administered probes during each of the 16 treatment sessions.

 

  • The data were analyzed using inferential statistics (ANOVA, t-tests) and descriptively.

 

 

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

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the efficacy of LSVT for Ps with presbyphonia.

 

POPULATION:  Presbyphonia; Adult

 

MODALITY TARGETED:  production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED :  loudness, pitch, duration

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: voice quality, laryngeal structure

 

DOSAGE:  4 one-hour sessions for 4 weeks (16 sessions)

 

ADMINISTRATOR:  SLP certified foe LSVT

 

MAJOR COMPONENTS:

 

  • Session structure

–  first 30 minutes

∞  maximize phonation time and pitch range; practice functional speech using short meaningful sentences using “shot loud” intensity.

–  second 30 minutes

∞  used increased loudness/intensity by increasing respiratory and phonatory effort in a variety of tasks:

  • reading aloud
  • questions
  •  word generation
  • conversation

 

  • Ps were assigned daily homework and when direct treatment was terminated, Ps were expected to complete daily practice routines to insure maintenance. Maintenance, however, was not targeted as an outcome in this investigation.

_________________________________________________________________