Behrman et al. (2020)

March 16, 2021

EBP THERAPY ANALYSIS

Treatment Groups

Note: Scroll about three-quarters of the way down the page to read the summary of the procedure(s).

Key:

 C =  Clinician

 CPP =  Cepstral peak prominence

 EBP =  evidence-based practice

 ICC = Interclass Correlation 

 NA = not applicable 

 P =  Patient or Participant

 PD =  Parkinson’s disease

 pmh =  Patricia  Hargrove, blog developer

 SD =  standard deviation 

 SLP =  speech–language pathologist

 V-RQol =  Voice-Related Quality of Life 

SOURCE:  Behrman, A., Cody, J., Elandary, S., Flom, P., & Chitna, S. (2020). The effect of SPEAK OUT! And the LOUD Crowd on dysarthria due to Parkinson’s disease. American Journal of Speech-Language Pathology, 29, 1448-1465. DOI: https://doi.org/10.1044/2020_AJSLP-19-00024

REVIEWER(S):  pmh

DATE: March 15, 2021

ASSIGNED GRADE FOR OVERALL QUALITY:  B+ The highest possible Overall Quality Grade, based on the design of this investigation (Prospective, Nonrandomized Group Design with Control), is B+. The Grade for Overall Quality should not be interpreted as a judgment of the quality of the intervention. Rather, it is a rating of the quality of the evidence supporting the intervention.

TAKE AWAY: This investigation explored the effectiveness of SPEAK OUT! and LOUD Crowd on the speech of patients (Ps) with Parkinson’s disease (PD). The findings indicated that following a course of 12 individual (40-minutes) sessions, measures of intensity and frequency improved. 

1.  What type of evidence was identified? 

• Prospective, Nonrandomized Group Design with Controls 

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

2.  Group membership determination: 

•  If there was more than one group, were participants (Ps) randomly assigned to groups? No  

•  If there were groups and Ps were not randomly assigned to groups, were members of groups carefully matched? Yes, for age and gender.

3.  Was administration of intervention status concealed?

•  from participants? No 

•  from clinicians? No

• from analyzers? Yes

4.  Were the groups adequately described?  Yes 

– How many  Ps were involved in the study? 

•  total # of Ps:  72

•  # of groups:  2     

     –  Parkinson’s disease (PD) group = 47 (40 completed the testing and treatment)

     –  Control (adults without communication disorders) group = 25

– CONTROLLED CHARACTERISTICS:

•  gender:

     – PD = ratio approximately 40% female; 60% male

     – Control = ratio approximately 40% female; 60% male

•  cognitive skills:

     – PD = sufficient to participate in therapy

•  stimulability:  

•  diagnosis:

     – PD = idiopathic PD

     – Control = no PD or communication disorders

•  communication disorders other than PD:

     – PD = No

     – Control = No

•  history of deep brain stimulation

     – PD = No

•  history of speech therapy within 2 yeas:

     – PD = No

•  neurological diagnoses other than PD:

     – PD = No

     – Control = No

•  medical procedures or diagnoses affecting speech:

     – PD = No

     – Control = No medical problems

•  proficiency in English:

     – PD = Yes

– DESCRIBED CHARACTERISTICS:

•  age:

     – PD = mean for males (m) = 69.6; mean for females (f) = 66.7

     – Control = mean for m = 69.7; mean for f = 66

•  time between diagnosis of PD and initial baseline:

     – PD = mean for m = 48 months; mean for f = 58.8 months

•  score on Hoehn & Yahr Scale:

     – PD = mean for m = 2; mean for f = 2

  age:

–   Were the groups similar before intervention began? Yes, for age and gender

–  Were the communication problems adequately described? No  

•  disorder type: dysarthria associated with PD

5.  Was membership in groups maintained throughout the study?

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

•  Were data from outliers removed from the study? No  

6.   Were the groups controlled acceptably? Yes 

  Was there a no intervention group? Yes, however, they were neurologically intact  

•  Was there a foil intervention group? No

•  Was there a comparison group?  No 

7.  Were the outcomes measure appropriate and meaningful? Yes 

•  OUTCOME #1: Mean intensity

•  OUTCOME #2: Standard deviation (SD) of intensity

•  OUTCOME #3: SD of frequency

•  OUTCOME #4: Cepstral peak prominence (CPP) 

•  OUTCOME #5: Voice-Related Quality of Life (V-RQoL)

–  One of the outcome measures was is subjective:      

          •  OUTCOME #5: Voice-Related Quality of Life (V-RQoL)

  Four of  the outcome measures were objective:        

          •  OUTCOME #1: Mean intensity

          •  OUTCOME #2: Standard deviation (SD) of intensity

          •  OUTCOME #3: SD of frequency

          •  OUTCOME #4: Cepstral peak prominence (CPP) 

8.  Were reliability measures provided?

–  Interobserver for analyzers?  Yes

     • For intensity measures the Interclass Correlation (ICC) coefficient = 0.94

     • For F0 measures the ICC coefficient = 0.92

  Intraobserver for analyzers?  Yes 

     • For intensity measures ICC coefficient = 0.97

     • For F0 measures the ICC coefficient = 0.96

  Treatment fidelity for clinicians?  No  

     • However, faithfulness to the SPEAK OUT! treatment protocol is achieved by extensive initial training and frequent follow-up training.

9.  What were the results of the statistical testing? 

Summary Of Related Results

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

PRE AND POST TREATMENT  ANALYSES

•  OUTCOME #1: Mean intensity

      – For monologue tasks both the men and women with PD intensity levels increased significantly from baseline to post-therapy with SPEAK OUT1!

      – For reading tasks both the men and women with PD intensity levels increased significantly from baseline to post-therapy following SPEAK OUT!

     – Intensity levels of the PD Ps were lower than the Control group at baseline but similar following SPEAK OUT!

•  OUTCOME #2: SD of intensity

      – For monologue tasks, both the men and women with P: intensity variation increased significantly from baseline to post-therapy with SPEAK OUT1!

      – For reading tasks, both the men and women with PD: intensity variation did not increase significantly from baseline to posttherapy with SPEAK OUT!

     – Intensity variation of the PD Ps was lower than the Control group at baseline and following SPEAK OUT!

     – The following did not have a significant effect on intensity variation:

          ∞ age, 

          ∞ gender, and

          ∞ attendance at LOUD Crowd sessions.

     – The following had a significant effect on intensity variation for monologues but not reading 

          ∞ Hoehn and Yahr scores (more severe PD associated with increased variation) and

          ∞ time from diagnosis to initial SPEAK OUT! session (less time since diagnosis associated with increased variation).

•  OUTCOME #3: SD of frequency. 

     – For monologue tasks, both the men and women with PD: frequency variation increased significantly from baseline to post-therapy with SPEAK OUT1!

      – For reading tasks, both the men and women with PD: frequency variation increased significantly from baseline to post-therapy with SPEAK OUT!

     – Frequency variation of the PD Ps was lower than the Control group at baseline and following SPEAK OUT!

•  OUTCOME #4: Cepstral peak prominence (CPP) 

     – Both the men and women significantly increased CPP from baseline to post-therapy with SPEAK OUT!

     – Overall, PD Ps produced significantly lower CPP than the Control group before therapy but after SPEAK OUT! the 2 groups were similar.

     – Some factors significantly affected CPP performance

          ∞ Women produced CPPs 2.5 dB higher than men.

          ∞ Higher Hoehn and Yahr scores were associated with higher CPP scores

•  OUTCOME #5: Voice-Related Quality of Life (V-RQoL)

     – Both the men and women significantly increased V-RQoL from baseline to post-therapy with SPEAK OUT!

     – V-RQoL of the PD Ps was lower than the Control group at baseline and following SPEAK OUT!

     – The following did not have a significant effect on V-RQoL:

          ∞ attendance at LOUD Crowd sessions and

          ∞ time from diagnosis to initial SPEAK OUT! session.

     – The following had a significant effect on V-RQoL: 

          ∞ Hoehn and Yahr scores (more severe PD associated with lower V-QRoL or poorer judgment of one’s voice) and

          ∞ gender (men’s scores increased more than women’s)

– The statistical test used to determine significance were 

•  t-test

•  Calculated Discontinuous Growth Curve Models

  Were confidence interval (CI) provided?  No 

10.  What is the clinical significance?   NA

11.  Were maintenance data reported?  No  

12.  Were generalization data reported? No  

13.  Brief description of the experimental design of the investigation.

• This investigation involved 2 groups of Ps:

      – 47 Ps with PD who were to be tested before and after receiving SPEAK OUT! and participating in LOUD Crowd. Forty of the PD Ps completed testing and treatment.

     – 25 Neurotypical (Control) Ps who were matched to the Ps with PD for age and gender. They were tested on the same schedule as the Ps with PD but they did not receive therapy.

• The pretesting (baseline) consisted of 3 sessions administered within a 2 or 3 week period and the post-testing involved 2 sessions, 1 and 6 weeks after treatment ended. 

• All 5 assessments elicited similar speech samples:

     – 1 minute monologue on a choice of 3 topics

     – reading aloud a designed passage

• The first baseline/pre-test and the first post-test also included the administration of the Hoehn and Yahr Rating (1st baseline/pre-test only) and the V-RQoL.

• The statistical analysis involved comparing

     – Ps with PD pre- and post- therapy score

     – Ps with PD pre-therapy (baseline) scores with Control groups pre-therapy scores

     – Ps with PD post-therapy scores with Control groups post-therapy scores

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: B+

SUMMARY OF INTERVENTION

PURPOSE: To investigate the effectiveness of SPEAK OUT! and LOUD Crowd

POPULATION:  Parkinson’s disease

MODALITY TARGETED:  production

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: intensity and frequency

OTHER TARGETS:  Ps perception of their voice 

DOSAGE: 12 individual session, 40 minutes, 3 times a week, 4 weeks (12 sessions, 8 hours) and participation in LOUD Crowd (weekly sessions following SPEAK OUT!)

ADMINISTRATOR: SLPs trained to use SPEAK OUT! and LOUD Crowd

MAJOR COMPONENTS:

• A complete summary of SPEAK OUT! and LOUD Crowd is provided in Table 3 of the article. (Wording in this summary is directly taken from Table 3 or a paraphrase of the wording.)

• There are 3 major components to the intervention:

     – SPEAK OUT!

     – LOUD Crowd

     – Homework assignments

SPEAK OUT!

• Before the initiation of treatment, the Participants (Ps) and their families attended an informational session covering the following topics:

     – neurophysiology of PD,

     – basic aspects of intentional and motor movement, 

     – explanation of homework assignments, and

     – rationale for maintenance involvement (i.e., LOUD Crowd).

• Ps were provided with SPEAK OUT! workbooks.

• The intervention involved 6+ procedures:         

  1. Warm up (production of nasal consonant initial words)
  2. Vowel Sustaining (production of a vowel for 10 seconds)
  3. Glide Sustaining (production of a vowel up and down the scale; final target was the P’s modal pitch)
  4. Numeral Sequencing (counting aloud but pausing every 3 to 5 numbers)
  5. Reading Aloud (P read aloud starting with phrases and ending with paragraphs)
  6. Cognitive-Linguistic Exercises (while targeting the production of intentional speech[PH1] , Ps participated in activities to elicit novel responses, improve word retrieval, and increase cognitive speed)

+   Conversational Speech also was a target throughout the sessions

• Cs employed specific verbal cues and shaping techniques to facilitate P production of targeted behaviors.

     ∞ Verbal Cues:

          – Speak with intent.

          – Be deliberate.

          – Speak out.

          – Say it like you mean it.

          – Say it purposefully.

          – Speak with your intentional voice, not your automatic voice.

     ∞ Shaping techniques:

          – Modeling

          – Visual cues

          – Self-monitoring

          – Internalized cueing of self-generated intentional speech

LOUD CROWD

• Ps attended their first LOUD Crowd meeting during the 3rd or 4th week of SPEAK OUT!

• Following the ending of SPEAK OUT!, it was recommended that Ps attend the weekly support group—LOUD Crowd.

• The procedures in LOUD Crowd were the same 6+ procedures described in SPEAK OUT!

HOMEWORK ASSIGNMENTS

• Homework was assigned from the workbook during SPEAK OUT! and LOUD Crowd.

• Dosage: 15 minutes per session,

     – during SPEAK OUT!: 1 time a day on therapy days, 2 times a day on nontherapy days 

     – during LOUD Crowd or completion of SPEAK OUT!: 1 time a day

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 [PH1]