Farazi et al.(2018)

October 20, 2020

EBP THERAPY ANALYSIS for 

Single Case Designs

NOTES: The summary of the intervention procedure(s) can be viewed by scrolling about two-thirds of the way down on this page.

Key:

 C = clinician

 DDK = diadochokinetic

 EBP = evidence-based practice

 MFT = Muscle Facial Treatment

 MIT = Melodic Intonation Therapy

 MPT = Maximum Phonation Time 

 NA = not applicable 

 P = patient or participant

 pmh = Patricia Hargrove, blog developer

 SLP = speech–language pathologist

 WNL = within normal limits

 wpm = words per minute 

SOURCE: Farazi, M., Amrevani, M., Ilkhani, Z., Amirzargar, N. (2018). Speech rehabilitation in Wilson’s disease: A case study. Case Reports in Clinical Practice, 3 (2), 44-49. https://crcp.tums.ac.ir/index.php/crcp

REVIEWER(S): pmh

DATE: October 20, 2020

ASSIGNED OVERALL GRADE:  D-  The highest possible Assigned Overall Grade for this article is D+ based on its experimental design. The Assigned Overall Grade does not reflect a judgment about the worth of the intervention; rather, it is a ranking of the evidence supporting the intervention.

TAKE AWAY: This case study of an Iranian patient (P) describes the speech characteristics of Wilson’s disease (WD). The investigators also describe a two-year course of treatment that resulted in communication improvement particularly in intelligibility.

1.  What was the focus of the research? Clinical 

2.  What type of evidence was identified?                              

• What  type of single subject design was used? Case Study – Description with Pre and Post Test Results

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

3.  Was phase of treatment concealed?                                              

•  from participant? No 

•  from clinicians? No 

• from data analyzers? No

4.  Was the participant (P) adequately described? Yes 

 How many Ps were involved in the study? 1

–  DESCRIBED CHARACTERISTICS 

•  age: 28 years at the beginning of the intervention

•  gender: female

•  cognitive skills: within normal limits (WNL); no dementia

•  expressive language: WNL

•  receptive language: WNL

•  respiratory support: inadequate

•  Oral Motor Skills: slowness, weakness of tongue, limited range of motion but lip puckering WNL

•  time since initial diagnosis: 10 years

•  Prosody:

     ∞ reduced loudness

     ∞ decreased pitch

     ∞ short phrases (duration?)

     ∞ increased speaking rate

– Were the communication problems adequately described? Yes

•  Disorder type: Dysarthria (severe) associated with WD

•  Other aspects of communication that were described:  

     ∞ Decreased Maximum Phonation Time (MPT)

     ∞ Reduced Intelligibility

     ∞ Impaired Articulation

     ∞ Impaired Oral Motor Skills including spasticity of the tongue muscles

     ∞ Prosody problems including reduced loudness, decreased pitch, short phrases (duration?), excessive speaking rate

     ∞ Improved Voice QualithY

5.  Was membership in treatment maintained throughout the study? Not applicable, there was only one P.

6.  Did the design include appropriate controls? No. It was a case study.

– Were baseline/preintervention data collected on all behaviors? Preassessment data were provided only for some outcomes.

– Did probes/intervention data include untrained stimuli? No Data were Provided  

– Did probes/intervention data include trained stimuli? No Data were Provided 

– Was the data collection continuous? No

 Were different treatment counterbalanced or randomized? NA  

7.  Were the outcome measures appropriate and meaningful? Yes 

•  OUTCOME #1: Increased intelligibility 

•  OUTCOME #2: Decreased speaking rate

•  OUTCOME #3Increased pitch

•  OUTCOME #4: Increased loudness

•  OUTCOME #5: Improved performance on diadochokinetic tasks

•  OUTCOME #6: Improved oral motor skills

•  OUTCOME #7: Improved respiratory support

•  OUTCOME #8: Improved speech sounds

•  OUTCOME #9: Improved voice quality

•  OUTCOME #10: Appropriate use of pauses

– The following outcomes are subjective:

•  OUTCOME #1: Increased intelligibility 

•  OUTCOME #5: Improved performance on diadochokinetic tasks

•  OUTCOME #6: Improved oral motor skills

•  OUTCOME #7: Improved respiratory support

•  OUTCOME #8: Improved speech sounds

•  OUTCOME #9: Improved voice quality

•  OUTCOME #10: Appropriate use of pauses

– The following objectives are objective

•  OUTCOME #2: Decreased speaking rate

•  OUTCOME #3Increased pitch

•  OUTCOME #4: Increased loudness

–  None the outcome measures was associated with reliability data.

8.  Results:

– Did the target behaviors improve when treated? Yes, for the most part although only limited data were provided. 

•  OUTCOME #1: Increased intelligibility 

     – Intelligibility prior to intervention was described as “extremely low and almost incomprehensible” (p. 45)

     – The investigators reported that following the intervention, P’s intelligibility improved approximately 50%, although some words remained unintelligible.

•  OUTCOME #2: Decreased speaking rate

     – Data collected prior to the intervention: words per minute (wpm) was reported to be marked higher than typical for an adult (105 wpm) 

     – The investigators reported that following the intervention, P’s speaking rate decreased.

•  OUTCOME #3Increased pitch

     – Prior to the intervention the P was described as monotone.

     – The investigators reported that following therapy pitch increased.

•  OUTCOME #4: Increased loudness

     – Prior to the intervention the P was described as exhibiting a low loudness level.

     – The investigators reported that following therapy loudness increased.

•  OUTCOME #5: Improved performance on diadochokinetic (DDK) task

     – The investigators reported that tongue movement was labored.

     – The investigators reported that DDK rate was 80% accurate over 10 seconds following therapy. 

•  OUTCOME #6: Improved oral motor skills

     – Before therapy, the investigators noted P

          ∞ displayed limited, slow, and weak tongue motion 

     – Following therapy, the P could move her tongue upwards. The investigators also reported that following therapy, P had more control over and increased sensory feedback from her oral motor muscles.

•  OUTCOME #7: Improved respiratory support

     – Data collected prior to the invention: MPT = between 2 and 3 seconds (standard = 20.96 seconds) 

     – Following 4 weeks of intervention MPT = 8 seconds and the investigators claimed that the P’s breathing capacity improved approximately 50%

•  OUTCOME #8: Improved production of speech sounds

     – Prior to the intervention the P was described as misarticulating /r/ and omitted phoneme(s)

     – P produced /r/ correctly in the initially, medially, and finally following therapy. 

•  OUTCOME #9: Improved voice quality

     – Prior to the intervention the P was described as exhibiting a breathy voice quality 

•   OUTCOME #10: Appropriate use of pauses

     – The investigators reported that the P had started to use appropriate pauses. 

9.  Description of baseline: 

–  Were baseline data provided?  No, some initial data were reported but they could not be considered baseline data.

10.  What is the clinical significance?  NA

11.  Was information about treatment fidelity adequate? No 

12.  Were maintenance data reported?  No  

13.  Were generalization data reported? No  

14.  Brief description of the design:

• This case study of an Iranian P diagnosed with Wilson’s disease (WD) described some of the communication characteristics of WD.

• In addition, the investigators described the major components and results of their 2-year intervention.

ASSIGNED OVERALL GRADE OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D-

SUMMARY OF INTERVENTION

PURPOSE: To explore the effectiveness of speech therapy for a P with Wilson’s disease

POPULATION: Wilson’s disease (WD); adults

MODALITY TARGETED: production

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

ELEMENTS OF PROSODY USED AS INTERVENTION (part of independent variable: intonation, rhythm

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: intelligibility, speech sounds, oral motor skills

DOSAGE:  overall length of speech therapy was 2 years, although length of various components varied or was not reported.

MAJOR COMPONENTS:

• The following were the major components of the intervention. Only those components designated associated with Speech therapy will be summarized in this review. 

     – Medicinal therapy

     – Behavior therapy

     – Speech therapy

          ∞ Diaphragmatic therapy

          ∞ Oral Movement therapy

          ∞ Melodic Intonation Therapy (MIT)

          ∞ Muscle Facial Treatment (MFT)

DIAPHRAGMATIC THERAPY

– Purpose: to improve P’s support for and control of respiration needed for speaking

– Dosage:  4 weeks of “intensive” therapy

– Procedures:

     ∞ The clinician (C) directed the P to lie down and to relax.

     ∞ C placed one hand on P’s abdomen and one hand on her chest.

     ∞ C directed P (a) to inhale through her nose and expand her abdomen and then (b) to exhale through her mouth and contract her abdomen.

MIT

– Purpose: To reduce monotonous pitch patterns, increase loudness, improve pausing, increase intelligibility. 

– Procedures:

     ∞ Produce rhythmic melodies

     ∞ Provide auditory feedback

ORAL MOVEMENT THERAPY

– Purpose: To improve muscle tone of oral structures, improve tongue movement, and increase the coordination of breathing and speech. In addition, the investigators claimed that improvement in these tasks resulted in the improved production of /r/.

– Procedures:

     ∞ The P engaged in 2 oral movement tasks:

          § Verbal DDK

          § Nonverbal DDK

MFT

– Purpose: To increase coordination of lip movements, increase function of the oral musculature, reduce drooling, improve articulation and intelligibility as well as fluency. 


Léard-Schneideer & Lévêque (2020)

October 1, 2020

ANALYSIS GUIDELINES

Comparison/Nonintervention Research 

KEY:

eta =   partial eta squared 

f = female

m = male

MBEA = the Montreal Battery of Evaluation of Amusia

MEC = Montreal Evaluation of Communication

MLU = mean length of utterance

NA = Not Applicable

P = participant or patient

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

TBI = traumatic brain injury 

WNL = within normal limits

SOURCE:  Léard-Schneider, L. & Lévêque , Y (2020). Perception of music and speech prosody after traumatic brain injury, PsyArXiv Preprints  https://psyarxiv.com/w7cbf/

REVIEWER(S):  pmh

DATE:  October 1, 2020

ASSIGNED GRADE FOR OVERALL QUALITY:  This is not an intervention study; therefore, there is no Assigned Grade for Overall Quality.

TAKE AWAY:   This investigation compared the performance of French-speaking participants (Ps) with traumatic brain injury (TBI) to a neurotypical peer group or test norms on music and prosody comprehension tasks. The results suggest that Ps with TBI encounter challenges with musical pitch discrimination, rhythm, affective prosody, and linguistic prosody.  

1.  What type of evidence was identified? 

• What was the type of design?  Comparison Research 

• What was the focus of the research? Clinically Related  

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

2.  Group membership determination: 

•  If there were groups, were participants randomly assigned to groups? No, the groups were TBI and Neurotypical Controls. This cannot be randomized.

 • If there were groups and Ps were not randomly assigned to groups, were members of groups carefully matched?  Yes, the groups reported similar gender distribution, age, and schooling.

3.  Were experimental conditions concealed?

•  from participants? No

•  from administrators of experimental conditions? No 

•  from analyzers/judges? No 

4.  Were the groups adequately described?  Yes 

–  How many participants were involved in the study? 

•  total # of Ps:  62

•  # of groups:  2

     Traumatic Brain Injury (TBI) = 31 (of 36 qualified volunteers, 5 were excluded for failing to meet al criteria)

     Neurotypical (NT) = 31 (of 33 qualified volunteers, 2 were omitted because they exhibited possible amusia)

•  Did all groups maintain membership throughout the investigation? Yes, but data was missing for 2 of the TBI group for the Lin Vowel task.         

CONTROLLED CHARACTERISTICS                                                      

•  age: 18 – 60 years

•  cognitive skills:  

•  native language: French

•  short-term memory: all TBI Ps demonstrated sufficient verbal comprehension on a standardized test

•  receptive language: all TBI Ps demonstrated sufficient verbal comprehension on a standardized test

•  severity of TBI: all Ps were rated as having severe TBI

     ∞ NT = none

•  Living Arrangements: only 1 TBI P lived independently

•  Hearing: all Ps within normal limits (WNL)

•  Amusia in NT Ps:  2 of 33 qualified NT volunteers were excluded because meet criterion on tasks identifying amusia.

DESCRIBED CHARACTERISTICS

•  age:  

     ∞ TBI = 38.1 years

     ∞ NT = 37.29 years

•  gender: 

     ∞ TBI = 32% women

     ∞ NT = 32%. women

•  schooling: 

     ∞ TBI = 48% ≤ 11 years

     ∞ NT = 48% ≤ 11 years

•  time post onset (TBI group only):

     ∞ less than 2 years = 25%

     ∞ 2 to 5 years = 23%

     ∞ more than 5 years = 52%

•  musical training (i.e., 3 or mor years of training)

     ∞ TBI = 4 Ps had prior musical training; all had stopped playing their instrument after their TBI.

•  Amusia in NT Ps: 2 of 33 qualified NT volunteers were excluded for failing the Montreal Battery of Evaluation of Amusia (MBEA)

  Were the groups similar? Yes 

•  Were the communication problems adequately described? No 

•  disorder type: Traumatic Brain Injury 

•  functional level:  severe

5.  What were the different conditions for this research?

–  Subject (Classification) Groups? Yes 

      • TBI

      • NT         

–  Experimental Conditions? No  

–  Criterion/Descriptive Conditions? Yes 

     • Performance on Scale portion of the MBEA

     • Performance on Rhythm portion of the MBEA

     • Performance on the Emotional Prosody Understanding portion of the Montreal Evaluation of Communication (MEC)

     • Performance on the Linguistic Prosody Understanding portion of the MEC

     • Performance on Emo Vowel task (accuracy of identifying emotions and the intensity of the emotions)]

     • Performance on Lin Vowel task [accuracy of identifying the intention (question, order, neutral/statement)]  

6.   Were the groups controlled acceptably? Yes 

7.  Were dependent measures appropriate and meaningful? Yes 

• OUTCOME #1: Performance on Scale portion of the Montreal Battery of Evaluation of Amusia (MBEA)

• OUTCOME #2:  Performance on Rhythm portion of the MBEA 

• OUTCOME #3: Performance on the Emotional Prosody Understanding portion of the Montreal Evaluation of Communication (MEC)

• OUTCOME #4:  Performance on the Linguistic Prosody Understanding portion of the MEC

• OUTCOME #5:  Performance on Emo Vowel task (accuracy of identifying emotions and the intensity of the emotions)

• OUTCOME #6:  Performance on Lin Vowel task [accuracy of identifying the intention (question, order, neutral/statement)  

–  All the dependent measures are subjective.

–  None of the dependent/ outcome measures are objective.

8.  Were reliability measures provided?                                   

•  Interobserver for analyzers?  No 

  Intraobserver for analyzers?  No 

•  Treatment or test administration fidelity for investigators?  No

9.  Description of design:  (briefly describe)

• Two groups of French-speaking adult volunteers (TBI and NT) were administered a battery of tests/tasks including those designed to assess musical recognition of pitch and rhythm as well as the comprehension of prosodic affect and linguistic prosody.

• The groups were similar for age, gender, and education.

• The results of correlational and gender analyses as well as results pertaining attitudes toward musi are not summarized in this review.

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

• OUTCOME #1: Performance on Scale (pitch) portion of the MBEA

     ∞ TBI group performed significantly more poorly than the NT

     ∞ 42 % of TBI Ps were classified as pathological

• OUTCOME #2:  Performance on Rhythm portion of the MBEA. 

     ∞ 52 % of TBI Ps were classified as Pathological 

• OUTCOME #3: Performance on the Emotional Prosody Understanding portion of the MEC

     ∞ the TBI and NT groups were not compared because the NT were not administered this task

• OUTCOME #4:  Performance on the Linguistic Prosody Understanding portion of the MEC

     ∞ the TBI and NT groups were not compared because the NT were not administered this task

• OUTCOME #5:  Performance on Emo Vowel task (accuracy of identifying emotions and the intensity of the emotions)

     § accuracy of affective prosody understanding was significantly lower for the TBI group than the NT group. d = 1.11

     § however, the perceived intensity of the emotion in the task was not significantly different for the NT versus the TBI groups

• OUTCOME #6:  Performance on Lin Vowel task [accuracy of identifying the intention (question, order, neutral/statement) 

     § accuracy of linguistic prosody understanding was significantly lower for the TBI group than the NT group. d = 1.11

∞ The descriptive analyses of correct responses for Outcomes 3, 4, 5, and 6 were combined:

     § pathological = equal or below 2 standard deviations below the performance of the NT groups or below cut-off on MBEA or MEC

     § 84% of the TBI groups had one or more of the above 4 Outcomes categorized as impaired/pathological.

     § 42% of the TBI groups had impaired affective and linguistic prosody understanding.

     § Approximately equal proportions of TBI Ps experienced problems with only affective (19%) or linguistic (23%) prosody.

     § Vowel based outcome tasks (i.e., Outcomes 5 and 6) were more of challenge than the sentence based, or MEC, outcome tasks (i.e., Outcomes 3 and 5).

          • for affective prosody, 55% of the Ps had a problem with the Vowel task (Outcome 5) compared to 35% for the sentences (Outcome 3).

          • for linguistic prosody, , 55% of the Ps had a problem with the Vowel task (Outcome 6) compared to 35% for the sentences (Outcome 4).

  What was the statistical test used to determine significance?

• Mann-Whitney U

•  Spearman

∞  Were effect sizes provided?   Yes

• OUTCOME #1: Performance on Scale (pitch) portion of the MBEA

     ∞ d = 1.04 (large effect)

• OUTCOME #5:  Performance on Emo Vowel task (accuracy of identifying emotions and the intensity of the emotions)

     ∞ d = 1.11 (large effect)

• OUTCOME #6:  Performance on Lin Vowel task [accuracy of identifying the intention (question, order, neutral/statement) 

     ∞ d = 1.11 (large effect)

∞  Were confidence interval (CI) provided?  No

11.  Summary of correlational results:   Not Applicable (NA)

12.  Summary of descriptive results:  Qualitative research. NA

13.  Brief summary of clinically relevant results:  

• Ps with TBI performed significantly more poorly on tasks measuring amusia as well as comprehension of affective and linguistic prosody.

• Ps with TBI were more likely to exhibit problems understanding affective and/or linguistic prosody than they were to exhibit amusia. That is, prosodic comprehension is more vulnerable than music processing following a TBI.

• Although not all Ps with TBI exhibited pathological music, affective prosody, and linguistic prosody, a large percentage of them did.

• Clinicians should consider assessing affective prosody, linguistic prosody, and music processing in Ps with TBI.

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  NA

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