Halpern et al. (2012)

December 1, 2017

EBP THERAPY ANALYSIS

Treatment Groups

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

Key:

C = Clinician

CI = Confidence Interval

EBP = evidence-based practice

f = female

LSVT Companion = Lee Silverman Voice Treatment Companion

LSVT Loud = Lee Silverman Voice Treatment Loud

m = male

NA = not applicable

P = Patient or Participant

PD = Parkinson disease

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE: Halpern, A. E., Ramig, L. O., Matos, C. E. C., Petska-Cable, J. A., Spielman, J. L., Pogoda, J. M., Gilley, P. M., Sapir, S., Bennett, J. K., & McFarland, D. H. (2012). Innovative technology for assisted delivery of intensive voice treatment (LSVT®LOUD) for Parkinson disease. American Journal of Speech-Language Pathology, 21, 354-367.

 

REVIEWER(S): pmh

 

DATE: November 29, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY: B (The highest possible grade based on the design of the investigation, a Prospective Randomized Group with Controls, is B+. The grade should not be construed to represent a judgment about the value of the intervention; it represents the quality of the evidence supporting the intervention.)

 

TAKE AWAY: This small group comparison investigation revealed that using an assistive technology (Lee Silverman Voice Treatment Companion, LSVT Companion) is an effective way to deliver Lee Silverman Voice Treatment Loud (LSVT-LOUD) for patients with Parkinson disease (PD.) LSVT-Companion allows the patient to self-administer some LSVT-LOUD sessions using interactive technology in the home. Improvement was noted in sound pressure level production and in several perceptual measures immediately following the termination of therapy and at 6 month post therapy follow up.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Randomized Group Design with Controls

                                                                                                          

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups? Yes

 

  1. Was administration of intervention status concealed?
  • from participants? No
  • from clinicians? No
  • from analyzers? Yes, for some outcomes.

                                                                    

 

  1. Were the groups adequately described? Yes

– How many Ps were involved in the study?

  • total # of Ps: 31
  • # of groups: 3
  • List names of groups and the # of participants in each group:

∞ Immediate Group = 9 (8 continued to the end of the intervention)

∞ Delayed Group = 9 (8 continued to the end of the intervention)

∞ Historical Group = 13

 

— CONTROLLED CHARACTERISTICS

  • cognitive skills: no evidence of dementia

 

  • medications:  optimally medicated at the beginning of the intervention. There were some changes during the course of the intervention.

 

  • diagnosis: Idiopathic PD

 

  • ability to use LSVT Companion: all Ps passed a usability test

 

— DESCRIBED CHARACTERISTICS:

  • age:

∞ Immediate Group = mean 65.8

∞ Delayed Group = mean 63.3

∞ Historical Group =   mean 68.5

 

  • gender:

∞ Immediate Group = 4f, 4m

∞ Delayed Group = 4f, 4m

∞ Historical Group = 6f, 7m

 

  • speech and voice severity (higher # = more severe):

∞ Immediate Group = 2.3

∞ Delayed Group = 2.0

∞ Historical Group = 2.7

 

  • emotional/psychological status: All Ps were free from severe depression

 

  • race: All Ps identified as white.

 

  • ethnicity: All Ps identified as not Hispanic or Latino

 

  • years post diagnosis:

∞ Immediate Group = 4.4

∞ Delayed Group = 4.7

∞ Historical Group = 8.5

 

  • severity of PD (higher # = more severe):

∞ Immediate Group = 1.9

∞ Delayed Group = 2.0

∞ Historical Group = not available

 

–   Were the groups similar before intervention began? Yes

                                                         

– Were the communication problems adequately described? Yes

  • disorder type: Parkinson disease, hypokinetic dysarthria
  • functional level: severity ratings of speech and volce ranged from 1 to 3.6 with average of 2.3 (Immediate group) and 2.0 (Delayed group.)

 

 

  1. 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?

Yes ____     No __x___     Unclear ____

 

 

  1. Were the groups controlled acceptably? Yes
  • Was there a no intervention group? Yes (actually it was a Delayed Intervention group
  • Was there a foil intervention group? No
  • Was there a comparison group? No

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

OUTCOMES:

                                                                                                             

  • OUTCOME #1: Vocal sound pressure (SPL) level during a portion of the Rainbow Passage

 

  • OUTCOME #2: SPL during maximum duration production of “Ah”

 

  • OUTCOME #3: SPL during a monologue

 

  • OUTCOME #4: SPL during a picture description task

 

  • OUTCOME #5: SPL during a fluency task

 

  • OUTCOME #6: Rating of better or worse from listeners

 

  • OUTCOME #7: Rating of improvements by Ps and their significant others

 

  • OUTCOME #8: Rating of usefulness of LSVT-Companion by Ps and their significant others

 

 

– The outcome measures that were objective are

  • OUTCOME #1: Vocal sound pressure (SPL) level during a portion of the Rainbow Passage

 

  • OUTCOME #2: SPL during maximum duration production of “Ah”

 

  • OUTCOME #3: SPL during a monologue

 

  • OUTCOME #4: SPL during a picture description task

 

  • OUTCOME #5: SPL during a fluency task

 

– The outcome measures that were subjective are

  • OUTCOME #6: Rating of better or worse from listeners

 

  • OUTCOME #7: Rating of improvements by Ps and their significant others

 

                                         

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Variable _x____, some of the Outcomes were associated with reliability data.

  • OUTCOMES #1 through 5 (i.e., SPL measures): no significant difference between the original rater and the reliability judge

 

  • OUTCOME #6 (i.e., perceptual rating by SLPs or graduate students in SLP): 90% of ratings were within 20 points

 

– Intraobserver for analyzers? Yes, for one outcome.

  • OUTCOME #6 (i.e., perceptual rating by SLPs or graduate students in SLP): 90% of ratings were within 20 points

 

– Treatment fidelity for clinicians? No, but the 3 SLPs who provided the intervention specialized in LSVT Loud.

 

 

  1. What were the results of the statistical (inferential) testing and/or the description of the results?

 

Summary Of Important Results

 

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

 

 

TREATMENT/NO TREATMENT GROUP ANALYSES

 

NOTE: The investigators provided extensive supporting data. Only selected results are summarized

 

  • OUTCOME #1: Vocal sound pressure (SPL) level during a portion of the Rainbow Passage

∞ Immediate Group = improved from Pre to Post intervention assessment; decrease from Post intervention to Follow-up assessment

∞ Delayed Group = improved from Pre to Post intervention assessment; decrease from Post intervention to Follow-up assessment

∞ Historical Group = improved from Pre to Post intervention assessment; decrease from Post intervention to Follow-up

 

  • OUTCOME #2: SPL during maximum duration production of “Ah”

∞ Immediate Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

∞ Delayed Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

∞ Historical Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

 

  • OUTCOME #3: SPL during a monologue

∞ Immediate Group = improved from Pre to Post intervention assessment; decrease from Post intervention to Follow-up assessment

∞ Delayed Group = improved from Pre to Post intervention assessment; decrease from Post intervention to Follow-up assessment

∞ Historical Group = improved from Pre to Post intervention assessment; decrease from Post intervention to Follow-up assessment

 

  • OUTCOME #4: SPL during a picture description task

∞ Immediate Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

∞ Delayed Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

∞ Historical Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

 

  • OUTCOME #5: SPL during a fluency task

∞ Immediate Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

∞ Delayed Group = improved from Pre to Post intervention assessment; no significant change from Post intervention to Follow-up

∞ Historical Group = data not available for this outcome

 

  • OUTCOME #6: Rating of better or worse from listeners

∞ Immediate and Delayed Groups = improvements were noted from PRE to POST measures

∞ Historical Group = data not available for this outcome

 

 

  • OUTCOME #7: Rating of improvements by Ps and their significant others

∞ Immediate Group =

  • 3 of the 16 Ps demonstrated a positive shift in self-ratings from Pre to Post assessment but, for the most part, even these were not maintained at Follow-Up. However, a total of 3 of the 16 Ps displayed a positive shift from Pre to Follow-Up
  • Significant others rated improvement for several, but not all of measures of improvement

∞ Delayed Group =

  • Significant others rated improvement some, but not all, measures of speech improvement;

∞ Historical Group = data not available for this outcome

 

  • OUTCOME #8: Rating of usefulness of LSVT-Companion by Ps and their significant others

∞ Immediate and Delayed Groups = ratings of helpfulness were primarily positive; all Ps claimed they could use the Companion;

∞ Historical Group =   data not available for this outcome

 

– What was the statistical test used to determine significance?

  • ANOVA
  • Fisher’s exact test
  • Sidak- Bonferroni correction
  • Tukey-Kramer correction

 

Were confidence interval (CI) provided? Yes , there was limited use of CIs.

 

– What was reported CI?

  • 95% CI:
  • reliability data reported for Outcome #7 was reported using CI
  • some of the data reported for Outcome #8 used CI

 

 

  1. What is the clinical significanceNA, no data were provided.

 

 

  1. Were maintenance data reported? Yes

– All of the outcomes were measured during a follow-up session (6 months after the termination of the interventions.)

 

– Most of the interventions remained the same or continued to improve at follow-up.

 

 

  1. Were generalization data reported? Yes

– The outcome measures were not directly targeted in therapy, they can be considered generalization data. The results suggest that there is considerable generalization.

 

 

  1. Describe briefly the experimental design of the investigation.

 

–   Sixteen Ps were randomized into 2 groups: those who received the intervention immediately (Immediate Group) and those who received the intervention following the completion of the Immediate Group’s intervention (Delayed Group.) All the Ps in the Immediate and Delayed Groups received treatment using LSVT- Companion.

 

– In addition, there was a Historical Group (n = 13) of Ps from a previously published investigation. These Ps had not received treatment using LSVT- Companion, rather they had received LSVT-LOUD and were included to investigate whether the progress using LVST-Companion was comparable to LSVT-LOUD.

 

– Ps from the current investigation (I.e.. Immediate and Delayed Groups) received 9 treatment sessions of in the clinic and 7 sessions at home using Companion (described in the Summary of Intervention Session.) The sessions in the home were self-administered by the P using LSVT-Companion.

 

– Ps in the Historical group had received 16 sessions of LVST-LOUD in the clinic.

 

–  All Ps were tested during 3 periods:

  • before the intervention (PRE)
  • immediately after the intervention (POST)
  • 6 months after the intervention ended (FOLLOW-UP)

 

– A small number of the Historical Groups outcomes were not available for analysis.

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: B

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: to investigate the effectiveness of an assistive technology (Companion) paired with traditional LSVT-LOUD therapy.

 

POPULATION: Parkinson disease; Adults

 

MODALITY TARGETED: expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness

 

ELEMENTS OF PROSODY USED AS INTERVENTION: Loudness

 

OTHER TARGETS: perception of improvement and usability

 

DOSAGE: 16 one-hour sessions; over 4 weeks (4 sessions a week)

 

ADMINISTRATOR: SLP qualified to administer LSVT-LOUD

 

MAJOR COMPONENTS:

 

 

  • LSVT-Companion follows the same procedures as LSVT-LOUD except LSVT-Companion uses technology to allow the P to be treated at home and to self-administer the program.

 

  • LSVT-Companion consisted of 9 LSVT-LOUD sessions administered in clinic and 7 sessions in which P used Companion at home.

 

  • The schedule for LSVT-Companion was
  • Week 1 = P received LSVT-LOUD from the clinician (C) 4 days. On the 4th day P also was trained to use the Companion.
  • Week 2 = At the clinic, C used Companion during Day 1 and asked P to operate it as independently as possible.
  • Week 3 = P and C used Companion on Day 1 and then C asked P to use it the rest of the week at home in place of the clinic sessions.
  • Week 4 = P worked in the clinic with C on Days 1 and 4 and with Companion on Days 2 and 3.

 

  • The Companion is an interactive computer program operated by the P that administers LSVT-LOUD procedures in the home. Companion allows the P to progress through the LVST-LOUD program at his/her own pace and provides audio and visual feedback to the P. In addition, the Companion generates data on selected acoustic variables (SPL, fundamental frequency, and duration), measuring the progress of the P.

 

  • The investigators did not provide a full description of LSVT-LOUD, although they provided several references.

 

 

_______________________________________________________________

 

 

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Theodoros et al. (2016)

February 11, 2017

 

EBP THERAPY ANALYSIS

Treatment Groups

 

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

 

Key:

C = Clinician

DIP = Dysarthria Impact Profile

EBP = evidence-based practice

f = female

FTF = face-to-face intervention

m = male

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = Patient or Participant

PD =   Parkinson’s Disease

PDQ-39 = Parkinson’s Disease Questionnaire-39

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE: Theodoros, D. G., Hill, A. J., & Russell, T. G. (2016.) Clinical and quality of life outcomes of speech treatment for Parkinson’s Disease delivered to the home via telerehabilitation: A noninferiority randomized controlled trial. American Journal of Speech-Language Pathology, 25, 214-232.

 

REVIEWER(S): pmh

 

DATE: February 7, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY: A- (The highest possible grade for overall quality of this investigation was “A” based on its experimental design, Prospective, Randomized Group Design with Controls.)

 

TAKE AWAY: Australian participants (Ps) with Parkinson’s disease (PD) enrolled in Lee Silverman Voice Treatment either face-to-face (FTF) or online. The FTF and Online interventions resulted in similar changes. Thus, as the result of both Online and FTF LVST, Ps experienced improvement in several loudness outcomes, ease of being understood, and reduced repetition requests. However, significant improvements in the following types of outcomes were not reported: pitch variability, intelligibility, and most quality of life indicators.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Randomized Group Design with Controls

                                                                                                           

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups? Yes, in the case where randomization was possible. (See item #4 –names of groups for explanation.)

                                                                   

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from clinicians? No

                                                                    

  • from analyzers? Yes, judges of perceptual measures were blinded.

                                                                    

 

  1. Were the groups adequately described? Yes

 

– How many Ps were involved in the study?

 

  • total # of Ps: 52
  • # of groups: 3
  • List names of groups and the # of participants in each group:
  • Face-to-Face (FTF) Intervention Metro Group n= 16, randomly assigned
  • Online Metro Group n = 15, randomly assigned
  • Online Non-Metro Group n = 21

 

– CONTROLLED CHARACTERISTICS

  • age: between 18 to 89 years
  • vision and hearing: sufficient to participate in investigation via teleconferencing
  • cognitive skills: sufficient to participate in investigation tasks
  • diagnosis: diagnosis of Parkinson’s Disease (PD) from a neurologist; hypokinetic dysarthria associated with PD
  • severity of PD: Stage 1 to 5 on the modified Hoehn and Yahr Scale
  • language: English
  • stimulability: for loud speech (sustained phonation, words, short phrases)
  • vocal structure and function: otolaryngologist reported consistent with PD
  • medication: stable throughout the investigation
  • comorbid neurological disorder other than PD: excluded
  • comorbid speech and language problems not associated with PD: excluded
  • comorbid vocal fold structure and function not associated with PD: excluded
  • comorbid respiratory dysfunction not associated with PD: excluded
  • history of alcohol abuse: excluded
  • diagnosis of dementia: excluded
  • previous experience with LVST: excluded

 

– DESCRIBED CHARACTERISTICS

  • age: overall mean 71.02; range 50-87*
  • gender: overall 36m, 16f*
  • time since diagnosis: overall 0.5 to 22 years*
  • stage of Parkinson’s Disease (PD): range 1 to 5 with majority in Stages 1 to 2.5
  • dysarthria: overallmild (77%), moderate (19%), severe (4%)*

* = no significant difference among the 3 grous

 

–   Were the groups similar before intervention began?

Yes, on the Described Characteristics signified with an asterisk (*) and the monologue Sound Pressure Level (Outcome #3.)

                                                         

– Were the communication problems adequately described? No

  • disorder type: dysarthria associated with PD

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

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

Yes _x__     No ___     Unclear

 

  • Were data from outliers removed from the study? Yes, outliers were removed from the following ratings

     – speech intelligibility

     – articulatory precision

     –   ease of understanding by partner

     – sustained phonation

     – loudness

     – articulatory precision

   – rating of communication on PDQ 39

 

 

  1. 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 comparison and the target groups constant? Yes

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

OUTCOMES

 

ACOUSTIC MEASURES:

  • OUTCOME #1: Increased loudness in dB of a sustained phonations
  • OUTCOME #2: Increased loudness in dB of a read passage
  • OUTCOME #3: Increased loudness in dB of a monologue
  • OUTCOME #4: Increased maximum fundamental frequency (F0) in Hz

 

PERCEPTUAL MEASURES:

  • OUTCOME #5: Improved perceived intelligibility
  • OUTCOME #6: Improved perceived pitch variability
  • OUTCOME #7: Improved perceived loudness
  • OUTCOME #8: Improved perceived vocal roughness
  • OUTCOME #9: Improved perceived articulatory precision
  • OUTCOME #10: Improved rating of communicative partner regarding ease of understanding
  • OUTCOME #11: Improved rating of communicative partner regarding the need to ask P for repetitions
  • OUTCOME #12: Improved rating of communicative partner regarding initiating conversation with familiar partners
  • OUTCOME #13: Improved rating of communicative partner regarding initiation conversation with unfamiliar partners
  • OUTCOME #14: Improved overall rating of communicative partner

 

QUALITY OF LIFE MEASURES

  • OUTCOME #15: P’s rating on the Dysarthria Impact Profile (DIP) of the effect of dysarthria on him/her as a person
  • OUTCOME #16: P’s rating on the DIP of his/her acceptance of dysarthria
  • OUTCOME #17: P’s rating on the DIP of how others react to dysarthria
  • OUTCOME #18: P’s rating on the DIP of how dysarthria affects others’ communication with him/her
  • OUTCOME #19: P’s overall rating on the DIP
  • OUTCOME #20: P’s rating on the Parkinson’s Disease Questionnaire-39 (PDQ-39) of overall communication
  • OUTCOME #21: P’s rating on the PDQ-39 of activities of daily living
  • OUTCOME #22: P’s rating on the PDQ-39 of cognition
  • OUTCOME #23: P’s rating on the PDQ-39 of emotion
  • OUTCOME #24: P’s rating on the PDQ-39 of social support
  • OUTCOME #25: P’s rating on the PDQ-39 of stigma
  • OUTCOME #26: P’s rating on the PDQ-39 of bodily discomfort
  • OUTCOME #27: P’s rating on the PDQ-39 of mobility
  • OUTCOME #28: P’s rating on the PDQ-39 summary

 

 

Outcomes 5 through 28 were subjective (i.e., the Perceptual and Quality of Life Outcomes.)

 

Outcomes 1 through 4 were objective (i.e., the Acoustic Outcomes.)

                                         

 

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Yes

  • OUTCOME #5: Improved perceived intelligibility = 0.82
  • OUTCOME #6: Improved perceived pitch variability = 0.36
  • OUTCOME #7: Improved perceived loudness = 0.84
  • OUTCOME #8: Improved perceived vocal roughness = 0.69
  • OUTCOME #9: Improved perceived articulatory precision = 0.83

 

– Intraobserver for analyzers? Yes

There were 2 judges for this task. The results for both are reporteD

  • OUTCOME #5: Improved perceived intelligibility = 0.98; 0.95
  • OUTCOME #6: Improved perceived pitch variability = 0.94; 0.96
  • OUTCOME #7: Improved perceived loudness = 0.90; 0.94
  • OUTCOME #8: Improved perceived vocal roughness = 0.92; 0.98
  • OUTCOME #9: Improved perceived articulatory precision = 0.80; 0.95

 

Treatment fidelity for clinicians? No

 

 

  1. What were the results of the statistical (inferential) testing and/or the description of the results?

 

SUMMARY OF RESULTS

 

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

 

 

TREATMENT AND COMPARISON TREATMENT GROUP ANALYSES

 

ACOUSTIC MEASURES:

  • OUTCOME #1: Increased loudness in dB of a sustained phonations

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #2: Increased loudness in dB of a read passage

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #3: Increased loudness in dB of a monologue (this was considered the primary outcome)

– using noninferiority analysis : it was determined that online treatment was NOT inferior to FTF treatment

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #4: Increased maximum fundamental frequency (F0) range in Hz

– no significant differences were noted for pre and post intervention results or for the different treatment groups

 

 

PERCEPTUAL MEASURES:

  • OUTCOME #5: Improved perceived intelligibility

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #6: Improved perceived pitch variability

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #7: Improved perceived loudness

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #8: Improved perceived vocal roughness

     – no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #9: Improved perceived articulatory precision

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #10: Improved rating of communicative partner regarding ease of understanding

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #11: Improved rating of communicative partner regarding the need to ask P for repetitions

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

  • OUTCOME #12: Improved rating of communicative partner regarding initiating conversation with familiar partners

– no significant differences were noted for pre and post intervention results or for the different treatment groups

 

  • OUTCOME #13: Improved rating of communicative partner regarding initiation conversation with unfamiliar partners

– no significant differences were noted for pre and post intervention results nor for the different treatment groups

 

  • OUTCOME #14: Improved overall rating of communicative partner

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

 

QUALITY OF LIFE MEASURES

– for 2 of the Quality of Life Measure (listed below)

  • OUTCOME #16: P’s rating on the DIP of his/her acceptance of dysarthria
  • OUTCOME #19: P’s overall rating on the DIP

significant differences were noted for pre and post intervention results but not for the different treatment groups

 

for most the Quality of Life Measures (listed below)   – no significant differences were noted for pre and post intervention results nor for the different treatment groups

  • OUTCOME #15: P’s rating on the Dysarthria Impact Profile (DIP) of the effect of dysarthria on him/her as a person
  • OUTCOME #17: P’s rating on the DIP of how others react to dysarthria
  • OUTCOME #18: P’s rating on the DIP of how dysarthria affects others’ communication with him/her
  • OUTCOME #20: P’s rating on the Parkinson’s Disease Questionnaire-39 (PDQ-39) of overall communication
  • OUTCOME #21: P’s rating on the PDQ-39 of activities of daily living
  • OUTCOME #22: P’s rating on the PDQ-39 of cognition
  • OUTCOME #23: P’s rating on the PDQ-39 of emotion
  • OUTCOME #24: P’s rating on the PDQ-39 of social support
  • OUTCOME #25: P’s rating on the PDQ-39 of stigma
  • OUTCOME #26: P’s rating on the PDQ-39 of bodily discomfort
  • OUTCOME #27: P’s rating on the PDQ-39 of mobility
  • OUTCOME #28: P’s rating on the PDQ-39 summary

 

 

– What statistical tests were used to determine significance?

  • ANOVA:
  • Friedman
  • Kruskal-Wallis
  • Analysis of Noninferiority
  • Chi Square

 

– Were confidence interval (CI) provided? No, but some were reportedly calculated in the statistical analyses.

 

 

  1. What is the clinical significance? NA

 

 

  1. Were maintenance data reported? No

 

  1. Were generalization data reported? Yes

 

  • Several of the measures could be considered generalization data because they are not taught in LVST. Measures which generalized included

– Ease of understanding

– Repetition requests

– Overall rating by communicative partner

– P’s acceptance of his/her dysarthria

– Overall DIP score

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • This was a prospective, randomized group study with controls.
  • The investigators use noninferiority methodology to determine if the targeted intervention (Online LVST) was statistically worse than the established (FTF LVST.)
  • There were 3 groups:

– 2 groups of Ps from the Metro area who were randomly assigned to either FTF or Online interventions

– 1 group of Ps from Rural areas

  • All Ps were tested before and after intervention on a variety measures. The different types of measures included

– Acoustic measures

– Perceptual measures

– Quality of Life measures

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: A-

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To determine if outcomes from Online administration of LVST are equivalent to FTF versions.

 

POPULATION: Parkinson’s Disease; Adults

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, pitch variation

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: intelligibility, vocal roughness, articulatory precision

OTHER TARGETS: Quality of life indicators

 

DOSAGE: 1 hour a day, 4 days a week, 4 weeks, for 1 month

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

  • The major components of the procedures will be discussed in 3 sections:

– LVST summary

– Online procedures

– FTF procedures

 

LVST SUMMARY

 

  • Purpose of LVST: to increase loudness and phonatory effort

 

  • Structure of Sessions:

– Repetitive Drills

  • Sustained Phonation
  • Pitch Range
  • Maximum loudness in functional speech

 

– Functional Speech Activities

 

– Assignment of Homework

 

 

ONLINE PROCEDURES

 

  • C administered the intervention in the home. P was linked to the C using videoconferencing.

 

  • Before intervention, the investigator taught P to use the videoconferencing equipment.

 

 

FTF PROCEDURES

 

  • C administered the intervention in a clinic room at the research institution

 


Cannito et al. (2012)

December 30, 2016

EBP THERAPY ANALYSIS

Treatment Groups 

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

Key:

C = Clinician

EBP = evidence-based practice

f = female

LVST = Lee Silverman Voice Treatment

m = male

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

RTM = regression to the mean

SLP = speech–language pathologist

 

 

SOURCE: Cannito, M. P., Suiter, D. M., Beverly, D., Chorna, L., Wolf, T., & Pfeiffer, R. M. (2012). Sentence intelligibility before and after treatment in speakers with idiopathic Parkinson’s disease. Journal of Voice, 26, 214-219.

 

 

REVIEWER(S): pmh

 

DATE: August 24, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: B-  (The highest possible grade based on the experimental design of the investigation was B.)

 

TAKE AWAY: This single group pre-post test intervention experiment yielded results supporting the effectiveness of Lee Silverman Voice Treatment (LVST) in improving intelligibility of patients (Ps) with Parkinson’s disease. Overall, intelligibility significantly improved following LVST and analyses of effectiveness for individuals revealed that 6 of the 8 Ps improved significantly. The investigators described characteristics of the 2 remaining Ps to identify possible reasons for their failure to progress using LSVT.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Single Group with Pre- and Post-Testing

                                                                                                          

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups? Not Applicable (NA), there was only one group.

 

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from clinicians? No

                                                                    

  • from analyzers? Yes

                                                                    

 

  1. Were the groups adequately described? Yes

 

– How many Ps were involved in the study?

 

  • total # of Ps: 8
  • # of groups: 1
  • names of group and the # of participants in each group: Patients (Ps) with idiopathic Parkinson’s disease = 8 Ps

 

– CONTROLLED CHARACTERISTICS

  • medications: all Ps maintained their medication usage during the investigation
  • diagnosis of hypokinetic dysarthria: by a certified speech-language pathologist (SLP)
  • on-going speech therapy: None of Ps received additional speech therapy during the investigation
  • previous therapy: None of the Ps had previously received Lee Silverman Voice Treatment (LVST)

 

– DESCRIBED CHARACTERISTICS

  • age:   52 to 81 years (mean = 66.3 years)
  • gender: 5m; 3f
  • medication: Varied among 7 of the Ps; 1P did not take medication
  • severity of hypokinetic dysarthria: Severe (1), Marked (2), Moderate (3), Mild (2)
  • years post onset: 2 to 27 years
  • Bilateral Deep Brain Stimulation: 1P
  • Bilateral pallidotomy: 1P
  • Hearing aids: 3Ps
  • Ambulation:

ambulatory (5Ps)

     – used walkers (2Ps);

     – used wheelchair (1P)

 

–   Were the groups similar before intervention began? NA

                                                         

– Were the communication problems adequately described? Yes

  • disorder type: all Ps were diagnosed with hypokinetic dysarthria, 7 Ps exhibited intelligibility problems
  • functional level: severity of the dysarthria varied: Severe (1), Marked (2), Moderate (3), Mild (2)

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

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

                                                               

  • Were data from outliers removed from the study? No

 

 

  1. Were the groups controlled acceptably? NA, there was only one group.

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

  • OUTCOME #1: Increased intensity (in dB) level of multiple productions of “ah.”
  • OUTCOME #2: Improved intelligibility (interpretation/transcription ) of read sentences

 

  • Outcome 2 was subjective.

 

  • Outcome 1 was objective.

                                         

 

  1. Were reliability measures provided?

                                                                                                            

  • Interobserver for analyzers? Yes

 

OUTCOME #2: Improved intelligibility (interpretation/transcription) of read sentences–

  • pretreatment interlistener reliability = 0.994
  • posttreatment interlistener reliability = 0.922

 

 

 

  • Intraobserver for analyzers?   Yes

 

– OUTCOME #2: Improved intelligibility (transcription) of read sentences–

  • intralistener reliability = 0.840
  • intraobserver reliability of the scoring of the transcriptions = 0.998

 

  • Treatment fidelity for clinicians? No, but the LVST was administered by an ASHA and LVST certified SLP.
  • If yes, describe

 

 

  1. What were the results?

 

PRE AND POST TREATMENT

 

  • OUTCOME #1: Increased intensity (in dB) level of multiple productions of “ah.”

– Overall, the post treatment intensity was significantly louder than the pre treatment intensity.

 

  • OUTCOME #2: Improved intelligibility (interpretation) of read sentences

– Overall post treatment intelligibility (85.82%) was significantly higher than pretreatment intelligibility (81.11%)

     – There was a significant difference among Ps. [NOTE: This did not remain significant following adjustment for regression to the mean (RTM).]

– The following interactions were significant:

  • treatment x P — suggests that Ps responded differently to treatment
  • days x P — some speakers responded differently on the days of data collection. This suggests either there was learning, RTM during the pre or post testing, or the measure is unstable for some Ps. (NOTE: There were 3 days of data collection for both pre and post testing and this did not remain significant following adjustment for RTM.)

     – RTM was detected among the pre and post scores.

     – Individual performances also were analyzed.

  • 6 Ps significantly increased intelligibility scores from pre to post treatment.
  • 1 P did not improve intelligibility significantly but increased intensity significantly. This P had been judged pretreatment to have adequate intelligibility with mild dysarthria.
  • 1 P decreased intelligibility from pre to post treatment.

 

  • What statistical tests were used to determine significance? t-tests (including nonparametric), ANOVA, Rocconi and Ethington RTM

 

  • Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance

 

  • Standardized Mean Difference (adjusted for RTM): d = 0.719 (large effect)

 

 

  1. Were maintenance data reported? No

 

  1. Were generalization data reported? No

 

 

  1. Describe briefly the experimental design of the investigation.
  • The investigators recruited 8 Ps with hypokinetic dysarthria associated with Parkinson’s disease.
  • An ASHA and LVST certified SLP administered LVST intervention of the Ps.
  • Each P participated in 4 individual sessions of LVST for 4 weeks.
  • Ps were tested on 3 consecutive days before (pretreatment) and after (post treatment):

– Read aloud test sentences (multiple listeners transcribed the sentences and then the sentences were scored for accuracy by different judges.)

– Sustained vocalizations of “ah” (measured in dB.)

  • The investigators presented clear descriptions of blinded listener and judge procedures and reliability measures.

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: B-

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of LVST in improving the intelligibility of speech of Ps with Parkinson’s disease

 

POPULATION: Parkinson’s disease; Adults

 

MODALITY TARGETED: Production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: intelligibility

 

DOSAGE: 4 days a week for 4 weeks

 

ADMINISTRATOR: SLP certified by ASHA and LVST

 

MAJOR COMPONENTS:

 

LVST

 

  • Procedures are only briefly described:

– This intensive behavioral treatment was administered individually 4 times a week for 4 weeks.

– It is based in motor learning theory and encourages Ps to “think loud” while maintaining healthy vocal production strategies.

 

 

_______________________________________________________________

 

 


Herd et al. (2012)

April 7, 2016

SECONDARY REVIEW CRITIQUE

 

 

KEY:

 

C = clinician

CI = confidence interval

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

SR = Systematic Review

 

 

Source: Herd, C. .P, Tomlinson, C. L., Deane, K. HO., Brady, M. C., Smith, C. H., Sackley, C., Clarke, C. E. (2012) Speech and language therapy versus placebo or no intervention for speech problems in Parkinson’s disease. Cochrane Database of Systematic Reviews, 2001, Issue 2. Art. No.: CD002812. DOI: 10.1002/14651858.CD002812. Update 2012

 

Reviewer(s): pmh

 

Date: April 4, 2016

 

Overall Assigned Grade: B (NOTE: The highest possible grade is A+ because this is a Systematic Review or SR. The Overall Assigned Grade is concerned with the quality of the design, the execution of the research, and the potential effectiveness of the intervention. For this SR, the grade was lowered because of the SR authors’ rating of the quality of the research supporting the interventions, not due to the quality of SR.)

 

Level of Evidence: A+ (Systematic Review with Narrow Criteria)

 

Take Away: This well-executed SR is a revision/update of a previously published SR. The authors of the SR identified 3 new investigations that met their narrow criteria and described the overall methodological quality of the 3 investigations as “poor.” The authors provided thorough analyses of the investigations and clearly justified their ratings. However, considering the scope of intervention research in Communication Sciences and Disorders, a speech-language pathologist (SLP) might be more generous with respect to grading of the 3 new investigations described in this SR. Each of the 3 interventions resulted in improvement in one or more of the following outcomes: loudness, monotonicity, pitch, and ratings of speech impairment. In addition, one of the interventions explored maintenance and determined that progress was maintained.

 

 

What type of secondary review? Meta Analysis

 

 

  • Were the results valid? Yes

 

– Was the review based on a clinically sound clinical question? Yes

 

– Did the reviewers clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)? Yes

 

– The authors of the secondary research noted that they reviewed the following resources:

  • abstracts from conferences
  • conference proceedings/abstracts
  • hand searches
  • internet based databases
  • references from identified literature
  • theses/dissertations
  • Controlled Trial Registers
  • Internal reports

 

– Did the sources involve only English language publications? Unclear

 

– Did the sources include unpublished studies? Yes

 

– Was the time frame for the publication of the sources sufficient? Yes

 

– Did the authors of the secondary research identify the level of evidence of the sources? Yes, the authors described the methodology as poor; they also provided a critique for each of the sources.

 

– Did the authors of the secondary research describe procedures used to evaluate the validity of each of the sources? Yes

 

Was there evidence that a specific, predetermined strategy was used to evaluate the sources? Yes

 

– Did the authors of the secondary research or review teams rate the sources independently? Yes

 

– Were interrater reliability data provided? No

 

– If there were no interrater reliability data, was an alternate means to insure reliability described? Yes, the authors reported that they rated the sources independently, discussed disagreements, and came to consensus regarding the disagreements.

 

– Were assessments of sources sufficiently reliable? Yes

 

– Was the information provided sufficient for the reader to undertake a replication? Yes

 

– Did the sources that were evaluated involve a sufficient number of participants? Variable. Although the authors of the SR were not impressed by the total number of Ps, it was respectable for the Communication Sciences and Disorders literature.

 

– Were there a sufficient number of sources? No.

 

  1. Description of outcome measures:

 

  • Outcome #1: Improved measures of loudness
  • Outcome #2: Improved measures of monotonicity
  • Outcome #3: Improved measures of pitch
  • Outcome #4: Improved ratings of speech impairment

 

 

  1. Description of results:

 

  • What measures were used to represent the magnitude of the treatment/effect size? Mean difference and effect

 

  • Summarize overall findings of the secondary research:

 

NOTE: The authors of the SR reworked the data from the 3 investigations/ sources to compare the outcomes of the treatment and no treatment groups because this was not provided in the original sources. Rather, the original sources/investigations had compared the pre and post intervention scores of the treatment and no treatment groups individually.

 

  • Outcome #1: Improved measures of loudness

Two of the 3 sources reported significant improvements for treatment groups compared to nontreatment groups in a variety of measures of loudness following intervention

 

  • Outcome #2: Improved measures of monotonicity

– Only 1 of the sources/investigations explored measures of monotonicity.

     – One measure of monotonicity (counting to 5 with their softest to their loudest volume) improved significantly with treatment; the other (singing up and down to the lowest to highest pitch) did not.

    

  • Outcome #3: Improved measures of pitch

–   Only 1 of the sources/investigations explored measures of pitch.

   –   The investigators of the source did not find a significant difference in measures comparing treatment and nontreatment groups

 

  • Outcome #4: Improved ratings of speech impairment

Two of the 3 sources/investigations reported that measures of overall speech impairment were significantly better for the treatment group compared to the nontreatment group.

 

– Were the results precise? Yes

 

– If confidence intervals (CI) were provided in the sources, did the reviewers consider whether evaluations would have varied if the “true” value of metrics were at the upper or lower boundary of the confidence interval? Unclear, CI were reported but not discussed thoroughly.

 

– Were the results of individual studies clearly displayed/presented? Yes

 

– Were the results in the same direction? Yes

 

– Did a forest plot indicate homogeneity? Yes

 

– Was heterogeneity of results explored? Yes, heterogeneity reported but it was not discussed.

 

– Were the findings reasonable in view of the current literature? Yes

– Were negative outcomes noted? Yes

                                                                                                                   

 

  • Were maintenance data reported? Yes. Only one of the investigations reported maintenance data (for loudness measures.) In all cases progress was maintained.

 

 

  • Were generalization data reported?  Unclear

 

 

 

SUMMARY OF INTERVENTION

 

 

Population: Parkinson’s Disease; Adults

 

Prosodic Targets: loudness, intonation (monotonicity), pitch

 

Nonprosodic Targets: speech impairment

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: loudness (for all 3 sources) and pitch (for 2 of the sources)

 

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

 

Description of Procedure/Source #1— Johnson & Pring (1990)

 

  • Group treatment focused on pitch and loudness.

 

  • The clinician (C) developed individual programs for the Ps and provided visual feedback.

 

Evidence Supporting Procedure/Source #1— Johnson & Pring (1990)

 

  • Compared to the no treatment group, Ps receiving this invention improved significantly more on measures of speech impairment, loudness, and maximum volume range (a measure of monotonocity.)

 

Evidence Contraindicating Procedure/Source #1— Johnson & Pring (1990)

 

  • It is not clear that the significant improvement in the measure of speech impairment is clinically significant.

 

  • There was not a significant improvement in maximum pitch range (a measure of monotonocity) or fundamental frequency.

 

 

Description of Procedure/Source #2—Robertson & Thomson (1984)

 

  • Group treatment focused on pitch and loudness as well as respiration, voice, and intelligibility. If needed, C provided individual therapy.

 

  • C provided visual feedback to the P using a video.

 

Evidence Supporting Procedure/Source #2— Robertson & Thomson (1984)

 

  • Compared to the no treatment group, Ps receiving this invention improved significantly more on a measure of speech impairment

 

 

Description of Procedure/Source #3—Ramig et al. (2001)

 

  • C administered Lee Silverman Voice Treatment (LSVT) which used healthy phonatory effort to increase loudness.

 

  • The sessions were individual sessions.

 

Evidence Supporting Procedure/Source #3— Ramig et al. (2001)

 

  • The results of statistical analyses of several measures of loudness reveal that loudness consistently improved significantly more after LVST treatment compared to no treatment.

 

  • The improvement was maintained 6 months after the termination of therapy.

de Azevedo et al. (2015)

February 1, 2016

EBP THERAPY ANALYSIS

Treatment Groups

 

 

Note: Scroll about two-thirds of the way down the page to read the summary of the procedure.

 

Key:

C = Clinician

EBP = evidence-based practice

f = female

F0 = fundamental frequency

LVST = Lee Silverman Voice Treatment

LVST-a = Lee Silverman Voice Treatment-adapted

m = male

NA = not applicable

P = Patient or Participant

PT = prominent tonic

PD = Parkinson’s disease

SLP = speech–language pathologist

UPT = unstressed pre-tonic

 

 

SOURCE: de Azevedo, L. L., de Souza, I. S., de Oliveira, P. M., & Cardose, F. (2015). Effect of speech therapy and pharmacological treatment in prosody of parkinsonians. Arquivos de Neuro-Psiquiatria i, 73 (1), 30 35. DOI: 10.1590/0004-282X20140193

 

REVIEWER(S):  pmh

 

DATE: January 30, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: C+ (Highest possible grade based on the experimental design was B.)

 

TAKE AWAY: A small group of Brazilian Portuguese speakers diagnosed with Parkinson’s disease (PD) were reported to show improvement in measures of fundamental frequency, duration, and intensity following an intervention that combined the drug Levodopa and an adaptation of the Lee Silverman Voice Treatment (LVST.)

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Single Group with Pre- and Post-Testing

 

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups? Not Applicable (NA), there was only one group.

 

  1. Was administration of intervention status concealed?
  • from participants? No
  • from clinicians? No
  • from data analyzers No

                                                                    

 

  1. Were the groups adequately described? No, the investigators provide some background on the Ps, more information would be helpful to those wishing to apply the findings clinically.

 

– How many Ps were involved in the study? 10

 

– total # of Ps: 10

 

– # of groups: 1

 

– The P characteristics that were CONTROLLED were i.

 

  • diagnosis: Ideopathic Parkinson’s disease
  • severity: Stages 2 or 3 on the Hoehn and Yahr Scale

 

– The P characteristics that were DESCRIBED were

  • age: 59 to 88 years
  • gender: 5m, 5f

 

   Were the groups similar before intervention began? NA, there was only one group

                                                         

– Were the communication problems adequately described? No

  • disorder type: Although the investigators did not list the disorder type, it can assumed that it was hypokinetic dysarthria

 

 

  1. Was membership in the group 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

 

 

  1. Were the groups controlled acceptably? NA, there was only one group.

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

The outcomes were

 

FUNDAMENTAL FREQUENCY (F0) OUTCOMES

  • OUTCOME #1: Highest F0 of the prominent pretonic (PT)
  • OUTCOME #2: Lowest F0 of the PT
  • OUTCOME #3: Amplitude of the melodic variation of PT
  • OUTCOME #4: Highest F0 of the unstressed pre-tonic (UPT); this occurs before the PT
  • OUTCOME #5: Lowest F0 of the UPT
  • OUTCOME #6: Amplitude of the melodic variation of UPT
  • OUTCOME #7: Highest F0 of the utterance
  • OUTCOME #8: Lowest F0 of the utterance
  • OUTCOME #9: Composition of the utterance
  • OUTCOME #10: Rate of change of melodic variation of PT (“composition divided by duration of PT”, p. 31)
  • OUTCOME #11: Rate of change of melodic variation of UPT (“composition divided by duration of UPT’, p. 31)
  • OUTCOME #12: Initial F0 of the utterance (abstracted from the middle of the first word of each utterance—“I”)
  • OUTCOME #13: F0 of the UPT (abstracted from the middle of the vowel of /a/ from the targeted utterances
  • OUTCOME #14: F0 of the PT (abstracted from the middle of the vowel /e/ from the targeted utterances
  • OUTCOME #15: Final F0 of utterance (abstracted from /a/ of the last word of the utterance)

 

DURATION OUTCOMES

  • OUTCOME #16: Duration of the PT
  • OUTCOME #17: Duration of the UPT
  • OUTCOME #18: Total duration of the utterance
  • OUTCOME #19: Starting point of the UPT
  • OUTCOME #20: Starting point of the PT

 

INTENSITY OUTCOMES

  • OUTCOME #21: Maximum intensity of the utterance
  • OUTCOME #22: Minimum intensity of the utterance
  • OUTCOME #23: Intensity variation of sentences
  • OUTCOME #24: Average intensity of sentences
  • OUTCOME #25: Average intensity of prolonged vowel

 

NONE of the outcome measures were subjective.

 

ALL of the outcome measures were objective.

 

                                         

  1. Were reliability measures provided?
  • Interobserver for analyzers? No
  • Intraobserver for analyzers?   No
  • Treatment fidelity for clinicians? No

 

 

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

 

  • Summary Of Important Results

 

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

 

 

PRE AND POST TREATMENT ONLY ANALYSES

 

  • The investigators analyzed gender differences but they are not highlighted in this review. Rather, if there was a significant difference between males and females, it is noted in the general results listed below.

 

PRETEST WITH Ps OFF LEVODOPA VS POSTTEST WITH Ps OFF LEVODOPA—Outcomes with significant differences

 

OUTCOME #6: Amplitude of melodic variation of UPTs (significantly higher for posttest)

OUTCOME #9: Composition of Utterance (significantly higher for posttest)

– Rate of change of UPT melodic variation (females were significant more pretest vs post test but not males)

OUTCOME #16: PT duration (significantly shorter for posttest)

OUTCOME #17: UPT duration (significantly higher for posttest)

OUTCOME #18: Utterance duration (durations were significantly shorter posttest compared to pretest for both males and females and durations were significantly shorter for females compared to males)

OUTCOME #24: Utterance intensity average (intensity was significantly lower for females in posttest compared to pretest.)

OUTCOME #25: Prolonged vowel intensity (significantly higher for posttest)

 

PRETEST WITH Ps OFF LEVODOPA VS POSTTEST WITH Ps ON LEVODOPA—Outcomes with significant differences

OUTCOME #10: Rate of change of PT melodic variation (significantly higher posttest)

OUTCOME #11: Rate of change of UPT melodic variation (significantly higher posttest)

OUTCOME #16: PT duration (significantly shorter posttest)

OUTCOME #18: Utterance duration (durations were significantly shorter posttest compared to pretest for both males and females and durations were significantly shorter for females compared to males)

OUTCOME #24: Utterance intensity average (intensity was significantly lower posttest compared to pretest for females)

OUTCOME #25: Prolonged vowel intensity (significantly longer for posttest)

 

 

PRETEST WITH Ps ON LEVODOPA VS POSTTEST WITH Ps ON LEVODOPA– Outcomes with significant differences

 

OUTCOME #3: Amplitude of PTs melodic variation—(significantly more posttest)

OUTCOME #6: Amplitude of UPTs melodic variation—(significantly more posttest)

OUTCOME #9: Composition of utterance —(significantly more posttest)

OUTCOME #10: Rate of change of PTs melodic variation—(significantly more posttest)

OUTCOME #11: Rate of change of UPTs melodic variation—(females produced significantly more posttest)

OUTCOME #17: UPTs duration —(females produced significantly more posttest)

OUTCOME #23: Intensity variation of utterance —(significantly more posttest)

OUTCOME #24: Utterance intensity average —(females produced significantly lower posttest)

 

 

  • What was the statistical test used to determine significance? F- test

 

  • Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance? NA, data not provided

 

 

  1. Were maintenance data reported? No

 

 

  1. Were generalization data reported? Yes, The focus of the intervention , LVST, is loudness. Therefore, the F0 (Outcomes 1-15) and duration (Outcomes 16 – 20) outcomes can be considered generalization.

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • Before (pretest) and after (posttest) the intervention, the Ps produced 3 sentences in Portuguese. They spoke each sentence with 4 different intents: the affects of certainty and doubt and the modes of declaration and interrogative. Ps also produced a prolonged vowel (/a/.)

 

  • In both the pre- and post- test contexts, Ps were recorded in 2 conditions:

– when P had been off Levodopa for 12 hours (off levodopa)

– when P had been administered Levedopa 1 hour previous to the testing (on levodopa.)

 

  • The investigators recorded the Ps’ productions during pre and post testing and acoustically analyzed them using the measures listed in the outcomes.

 

  • The investigators administered an adapted version of the Lee Silverman Voice Treatment-adapted (LVST-a.) See the summary section below for the description of the adaptation/dosage.

 

  • The investigators compared the Ps’ performances by acoustically measuring the stimuli (sentences and prolongation of the vowel /a/) in 3 comparison contexts:

– Pretest with Ps off levodopa vs Posttest with Ps off levodopa

– Pretest with Ps off levodopa vs Posttest with Ps on levodopa

– Pretest with Ps on levodopa vs Posttest with Ps on levodopa

 

  • The investigators collapsed data across sentence types (certainty, double, statement, question) and most of the gender analyses in their statistical analyses.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C+

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of an intervention involving a combination of Levodopa and LVST-a.

 

POPULATION: Parkinson’s disease

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: Pitch, Intonation, Loudness, Duration, Rate of Speech

 

ELEMENTS OF PROSODY USED AS INTERVENTION: Loudness

 

DOSAGE: 16 individual 50-minute sessions, 2 times a week for 2 months

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

  • The investigators reported that they adapted the Lee Silverman Voice Treatment program by changing the dosage of the intervention. Instead of administering 16 sessions, 4 times a week, for 1 month they administered 16 sessions, 2 times a week, for 2 months.

 


Ramig et al. (2001b)

September 5, 2014

EBP THERAPY ANALYSIS

Treatment Groups

 

Note: Scroll about two-thirds of the way down the page to read the summary of the procedures.

 

Key:

C = Clinician

EBP = evidence-based practice

f = female

LSVT = Lee Silverman Voice Treatment

m = male

NA = not applicable

P = Patient or Participant

PD = Parkinson’s disease

pmh = Patricia Hargrove (blog developer)

RET = respiratory therapy

UPDRS = Unified Parkinson’s Disease Rating Scale

SLP = speech–language pathologist

SPL = sound pressure level, a measure of loudness

STSD = semi-tone standard deviation, a measure of inflection/intonation

 

 

SOURCE: Ramig, L. O., Sapir, S., Countryman, A. A., O’Brien, C., Hoehn, M., & Thompson, L. L. (2001b). Intensive voice treatment for patients with Parkinson’s disease: A 2 year follow up. Journal of Neurological and Neurosurgical Psychiatry, 71, 493-498.

 

REVIEWER(S): pmh

 

DATE: September 5, 2014

 

ASSIGNED GRADE FOR OVERALL QUALITY: B+ (The highest possible grade, based on the design was A.)

 

TAKE AWAY: The investigators compared outcomes from Lee Silverman Voice Treatment (LSVT) and respiratory therapy (RET) for speakers with Parkinson’s disease. LSVT outperformed RET on acoustic outcomes measuring loudness and intonation. The gains made using LSVT persisted for 2 years following treatment.

 

  1. What type of evidence was identified?
  2. What was the type of evidence? Prospective, Randomized Group Design with Controls
  3. What was the level of support associated with the type of evidence? Level = A

                                                                                                           

 

  1. Group membership determination:
  2. If there were groups, were participants randomly assigned to groups? Yes, but only after they had been stratified.

 

 

  1. Was administration of intervention status concealed?
  2. from participants? No
  3. from clinicians? No
  4. from analyzers and test administrators? Yes

                                                                    

 

  1. Were the groups adequately described? Yes, for the most part but see 4a and 5a.
  2. How many participants were involved in the study?
  • total # of participant:   29 [the original group was larger but the number of participants (Ps) that withdrew was not specified]
  • # of groups: 2
  • # of participants in each group: 21, 12 and data was not collected for all outcomes at all testing times – pre, post, follow-up (2 years after termination of treatment)
  • List names of groups: LSVT (21); RET (12)

                                                                                

  1. The following characteristic was controlled:
  • Ps were excluded if laryngeal pathology not related to PD. That is, none of the Ps exhibited laryngeal pathology not related to PD.

 

The following characteristics were described:

  • age: mean ages—LSVT 61.3; RET 63.3
  • gender: LSVT (17m, 4f); RET (7m, 5f)
  • Unified Parkinson’s Disease Rating Scale (UPDRS): LSVT = 27.7; RET 12.9
  • Stage of disease: LSVT = 2.6; RET = 2.2
  • time since diagnosis: LSVT = 7.2 years; RET = 5.0 years
  • medication: all Ps were optimally medicated and medications did not change over course of investigation

 

  1. Were the groups similar before intervention began? Yes but preintervention differences between groups on UPDRS and Stage were not reported.

                                                         

  1. Were the communication problems adequately described? Yes
  • disorder type: (List) dysarthria associated with Parkinson’s disease
  • Speech severity rating: LSVT = 1.2; RET = 1.7 (1 = mild; 5= severe)
  • Voice severity rating: LSVT = 2.5; RET = 2.3 (1 = mild; 5= severe)

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

  1. Did each of the groups maintain at least 80% of their original members? Unclear. There was some attrition but it was not described.
  2. Were data from outliers removed from the study? No

 

  1. Were the groups controlled acceptably? Yes
  2. Was there a no intervention group? No
  3. Was there a foil intervention group? No
  4. Was there a comparison group? Yes
  5. Was the time involved in the foil/comparison and the target groups constant? Yes

 

  1. Were the outcomes measure appropriate and meaningful? Yes
  2. List outcomes
  • OUTCOME #1: Increase sound pressure level (SPL) during production of “ah”
  • OUTCOME #2: Increase SPL during reading of the “Rainbow” passage
  • OUTCOME #3: Increase SPL during 25-30 seconds of monologue
  • OUTCOME #4: Increase semitone standard deviation (STSD) during reading of the “Rainbow” passage
  • OUTCOME #5: Increase STSD during 25-30 seconds of monologue

 

  1. None of the outcome measures are subjective.

                                         

 

  1. Were reliability measures provided? Yes
  2. Interobserver for analyzers? Yes.
  • The investigators only provided data for STSD measures (i.e., outcomes #4 and #5). They claimed that previous reports indicated SPL (outcomes #1, #2, and #3) were reliable.
  • OUTCOME #4: Increase semitone standard deviation (STSD) during reading of the “Rainbow” passage—greater than 0.97
  • OUTCOME #5: Increase STSD during 25-30 seconds of monologue –greater than 0.97

 

  1. Intraobserver for analyzers? No

 

  1. Treatment fidelity for clinicians? No. There were no data supporting reliability. However, the clinicians worked together during the sessions with the purpose of achieving consistency in application of the interventions.

 

  1. What were the results of the statistical (inferential) testing?
  2. Data analysis revealed:

 

TREATMENT GROUP VERSUS COMPARISON TREATMENT GROUP

 

  • OUTCOME #1: Increase sound pressure level (SPL) during production of “ah”—LSVT significantly higher than RET at post-treatment and 2-year follow-up
  • OUTCOME #2: Increase SPL during reading of the “Rainbow” passage —LSVT significantly higher than RET at post-treatment and 2-year follow-up
  • OUTCOME #3: Increase SPL during 25-30 seconds of monologue —LSVT significantly higher than RET post-treatment
  • OUTCOME #4: Increase semitone standard deviation (STSD) during reading of the “Rainbow” passage —LSVT significantly higher than RET post-treatment
  • OUTCOME #5: Increase STSD during 25-30 seconds of monologue—No significant differences between groups

 

 

PRE VS POST TREATMENT (only significant changes are noted)

 

  • OUTCOME #1: Increase sound pressure level (SPL) during production of “ah”

–LSVT: significant improvement from pre to post

–LSVT: significant improvement from pre to 2-year follow up

 

  • OUTCOME #2: Increase SPL during reading of the “Rainbow” passage

–LSVT: significant improvement from pre to post

–LSVT: significant improvement from pre to 2-year follow up

–RET: significant improvement from pre to post

 

  • OUTCOME #3: Increase SPL during 25-30 seconds of monologue

–LSVT: significant improvement from pre to post

–LSVT: significant improvement from pre to 2-year follow up

 

  • OUTCOME #4: Increase semitone standard deviation (STSD) during reading of the “Rainbow” passage

–LSVT: significant improvement from pre to post

–LSVT: significant improvement from pre to 2-year follow up

–RET: significant improvement from pre to post

 

  • OUTCOME #5: Increase STSD during 25-30 seconds of monologue

–LSVT: significant improvement from pre to post

–LSVT: significant improvement from pre to 2-year follow up

 

  1. What was the statistical test used to determine significance? ANOVA and t-tests.

 

  1. Were confidence interval (CI) provided? No

 

                                               

  1. What is the clinical significance? NA. No EBP data were provided.

 

 

  1. Were maintenance data reported? Yes. The investigators retested Ps two years after the end of the intervention. For LSVT, all outcomes that improved significantly from pre to post intervention also improved from pre to 2-year follow up. For RET, neither of the improved outcomes significantly increased from pre to 2 year follow up.

 

  1. Were generalization data reported? No

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: B+

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of LSVT

 

POPULATION: Parkinson’s disease

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, intonation

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness, pitch range, duration

 

OTHER TARGETS:

 

DOSAGE: 16 sessions (4 sessions per week for 4 weeks), 1-hour sessions

 

ADMINISTRATOR: 2 SLPs

 

STIMULI: auditory stimuli, visual feedback

 

MAJOR COMPONENTS:

 

  • Two treatments were compared: Lee Silverman Voice Treatment (LSVT) and respiratory therapy (RET). Both interventions

– focused on high and maximum effort

– included exercises for the first half of the session and speech tasks for the second half of the session

– assigned daily homework

 

LSVT
• Purpose: to increase loudness by increasing (vocal) effort

  • C was careful to avoid vocal hyperfunction while encouraging P to increase effort.
  • To increase vocal effort, C led P in lifting and pushing tasks.
  • Drills included prolongation of “ah” and fundamental frequency range drills
  • C encouraged P to use maximum effort during treatment tasks by reminding P to “think loud” and to take a deep breath.

 

RET

  • Purpose: to increase respiratory muscles function thereby improving volume, subglottal air pressure, and loudness
  • Tasks: inspiration, expiration, prolongation of speech sounds, sustaining intraoral air pressure
  • C encouraged P to use maximal respiratory effort, cued P to breathe before tasks and during reading/conversational pauses
  • C provided visual feedback to P using a Respigraph.

 

 


McMicken et al (2011)

August 16, 2014

Single Subject Designs

 

Notes:

 

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

 

  1. Key:

C = clinician

GILCU = Gradual Increase of Length and Complexity of Utterances) from RFP

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = participant or patient

pmh = Patricia Hargrove, blog developer

RFP = Ryan Fluency Program

WNL = within normal limits

 

SOURCE: McMicken, B. L., Ostergren, J. A., & Vento-Wilson, M. (2011). Therapeutic intervention in a case of ataxic dysarthria associated with a history of amateur boxing. Communication Disorders Quarterly, 33, 55-64. doi: 10.1177/1525740110397829

 

REVIEWER(S): pmh

 

DATE: August 16, 2014

ASSIGNED OVERALL GRADE: D (The highest possible grade was D+ because this was a case study.)

 

TAKE AWAY: This case study describes an intervention combining Lee Silverman Voice Treatment (LSVT) and the Ryan Fluency Program (RFP) for the treatment of speech associated with ataxic dysarthria in a patient (P) with a history of boxing. The results suggest the combined intervention was moderately successful in improving perception of severity and intelligibility as well as diadokokenesis skills. However, the P’s self-perception of his communication skills decreased markedly

 

  1. What was the focus of the research? Clinical Research

                                                                                                           

 

  1. What type of evidence was identified?
  2. What type of single subject design was used? Case Studies– Description with Pre and Post Test Results
  3. What was the level of support associated with the type of evidence? Level = D+

                                                                                                           

 

  1. Was phase of treatment concealed?
  2. from participants? No
  3. from clinicians? No
  4. from data analyzers? No

 

 

  1. Were the participants adequately described? Yes
  2. How many participants were involved in the study? 1

 

  1. The following characteristics were described:
  • age: 36 years
  • gender: m
  • cognitive skills: WNL

                                                                                                             

  1. Were the communication problems adequately described? Yes
  • List the disorder type(s):
  • List other aspects of communication that were described:
  • oral mechanism:   WNL
  • motor speech skills: WNL
  • diadochokinesis (alternating motion rates): slow, irregular, uneven, frequent misarticulation (especially voicing and vowel distortion), irregular speed
  • vowel prolongation: WNL
  • intelligibility: 3.7 on a 7 point scale (7 was the best rating)
  • impairment severity: marked/severe
  • misarticulations: inconsistent
  • stress: excessive and equal
  • duration: prolongation of speech sounds

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Yes
  2. If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable
  3. Were any data removed from the study? No

 

 

  1. Did the design include appropriate controls? No. This was a case study
  2. Were preintervention data collected on all behaviors? Yes, but these data were not easy to find.
  3. Did probes/intervention data include untrained data? NA
  4. Did probes/intervention data include trained data? NA
  5. Was the data collection continuous? NA
  6. Were different treatment counterbalanced or randomized? Not Applicable

 

  1. Were the outcomes measure appropriate and meaningful? Yes
  2. The outcomes were

OUTCOME #1: To increase the duration of vowel prolongations

OUTCOME #2: To increase the number of repetitions per seconds in a diadokokinesis (alternating motion) task

OUTCOME #3: To improve (decrease) severity ratings

OUTCOME #4: To improve (increase) intelligibility ratings

OUTCOME #5: To improve P’s self perception of his communication skills

  1. The outcomes that were subjective are

OUTCOME #3: To improve (decrease) severity ratings

OUTCOME #4: To improve (increase) intelligibility ratings

OUTCOME #5: To improve P’s self perception of his communication skills

  1. The outcomes that were objective are

OUTCOME #1: To increase the duration of vowel prolongations

OUTCOME #2: To increase the number of repetitions per seconds in a diadokokinesis (alternating motion) task

                                                                                                             

  1. The outcome measures with reliability data are

OUTCOME #3: To improve (decrease) severity ratings

OUTCOME #4: To improve (increase) intelligibility ratings

  • Combined reliability across 3 judges for OUTCOMES #3 and #4 was at least 92%.

 

 

  1. Results:
  2. Did the target behavior improve when it was treated? Inconsistent
  3. b. The outcomes overall quality of improvement for each of the Outcomes was

OUTCOME #1: To increase the duration of vowel prolongations—limited improvement but pretreatment data were within normal limits

OUTCOME #2: To increase the number of repetitions per seconds in a diadokokinesis (alternating motion) task—moderate—the number of repetitions improve slightly but productions were more regular with fewer distortions and substitutions

OUTCOME #3: To improve (decrease) severity ratings—moderate improvement. The P progressed from marked to severe impairment (pretreatment) to mild to moderate (post treatment)

OUTCOME #4: To improve (increase) intelligibility ratings—moderate improvement. P progressed from an overall intelligibility rating of 3.7 (pretreatment) to 5.3 (posttreatment) on a 7-point scale.

OUTCOME #5: To improve P’s self perception of his communication skills—ineffective. P’s perception of his communication skills decreased following intervention.

  1. Description of baseline:
  2. Were baseline data provided? No, the investigators only provided pretreatment data.

 

 

  1. What was the magnitude of the treatment effect? NA

 

 

  1. Was information about treatment fidelity adequate? Not Provided

 

 

  1. Were maintenance data reported? No but the investigators did note there was a maintenance phrase of treatment.

 

 

  1. Were generalization data reported? Yes. None of the outcomes were direct targets of intervention. Therefore, all of them could be considered generalization data. See item #8 for these results.

 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: ____D _____

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of treatment combining LSVT and RFP in improving the speech of a P with ataxic dysarthria associated with a history of boxing.

POPULATION: Ataxic Dysarthria; Adult

 

MODALITY TARGETED: expression

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rate, loudness

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION/SPEECH TARGETED: vowel prolongation, diadokokinesis, intelligibility, severity of speech impairment

 

OTHER TARGETS: self-perception of communication skills

DOSAGE: 25 session, 2 times a week, for 50 minutes

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

  • The intervention combined LSVT with components (GILCU, Gradual Increase of Length and Complexity of Utterances) of RFP.

LSVT:

– C instructs P to think loud and/or focus on producing a loud voice.

– C provides feedback to P about the effectiveness of attempts to speak loudly.

– C uses the following forms of feedback/reinforcement

  1. Incorrect responses = “Stop, speak loudly and clearly.”
  2. Correct responses (i.e., a loud and clear production) = “Good.”

GILCU of RFP:

– C orders speech targets to increase length and complexity in 3 contexts

  1. conversation
  2. reading
  3. monologue

 

  • There were 3 phases of treatment: establishment, transfer, and maintenance:

ESTABLISHMENT

– C presents targets in a specified order:

  1. each level increases in length/complexity from the previous level.
  2. to progress through a level, P must produce 10 correct responses for each step within the level
  3. within each level (e.g., one-word utterances, two-word utterances, etc.), the steps involve
  4. reading
  5. conversation
  6. monologue
  7. After reaching criterion, C adds time to the task, gradually increasing the reading, conversation, and monologue from 30 seconds to 5 minutes.
  8. The investigators provided an appendix with detailed instruction for this phase.
  9. Throughout the Establishment phase, C provides feedback regarding loudness and sound production.

TRANSFER

  1. At the beginning of the transfer phase, C provides feedback regarding loudness and sound production.
  2. P presents a 10-minute impromptu presentation at lunchtime at the treatment facility.
  3. C initiates interactions with other communicative partners within the treatment facility or the community, instructing P to speak as long as possible to the communicative partners.
  4. C also works to change the context from the therapy room to locations in the community.

MAINTENANCE

  1. C no longer provides feedback to P regarding the correctness of productions. Rather, P self monitors and describes his own speech production.