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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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.

 

 

_______________________________________________________________

 

 


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.

Theodoros & Ramig (2011)

May 23, 2014

SECONDARY REVIEW CRITIQUE

 

NOTE: Scroll down about two-thirds of this page to read the Summary of the Intervention procedure.

 

Source: Theodoros, D., & Ramig, L. (2011, October). Telepractice supported delivery of LSVT®Loud. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders,21, 107-119.  doi:10.1044/nnsld21.3.107

 

Reviewer(s): pmh

 

Date: May 17, 2014

 

Overall Assigned Grade: D- (Highest possible grade is D.)

 

Level of Evidence: D

 

Take Away: This traditional narrative review provides a guide to incorporating Lee Silverman Voice Treatment (LVST-Loud) into telepractice and reviews research documenting its effectiveness as well as its costs and P satisfaction.

 

What type of secondary review? Narrative Review

 

1. Were the results valid? Yes

 

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

b. Did the reviewers clearly describe reasonable criteria for inclusion and exclusion of literature in the review? No

c. Authors noted that they reviewed the following resources: (place X next to the appropriate resources) The authors did not describe their search strategy.

d. Did the sources involve only English language publications? Yes

e. Did the sources include unpublished studies? Yes

f. Was the time frame for the publication of the sources sufficient? Yes

g. Did the reviewers identify the level of evidence of the sources? No

h. Did the reviewers describe procedures used to evaluate the validity of each of the sources? No

i. Was there evidence that a specific, predetermined strategy was used to evaluate the sources? No

j. Did the reviewers or review teams rate the sources independently? No

k. Were interrater reliability data provided? No

l. If the reviewers provided interrater reliability data, list them: NA

m. If there were no interrater reliability data, was an alternate means to insure reliability described? No

n. Were assessments of sources sufficiently reliable? Not Applicable

o. Was the information provided sufficient for the reader to undertake a replication? No

p. Did the sources that were evaluated involve a sufficient number of participants? Variable

q. Were there a sufficient number of sources? No

2. Description of outcome measures:

• Outcome #1: improved sound pressure level

• Outcome #2: Improved pitch range (acoustic and/or perceptual)

• Outcome #3: Improved perceived loudness level

• Outcome #4: Improved perceived loudness variability

• Outcome #5: Improved breathiness

• Outcome #6: Improved performance on overall measures of perceived voice quality

• Outcome #7: Improved performance on overall measures of oromotor skills

• Outcome #8: Improved performance on overall measures of articulatory precision

• Outcome #9:Improved performance on measures of intelligibility

• Outcome #10:Improved performance on measures of duration

 

 

3. Description of results:

a. What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? NA, none were provided.

b. Summarize overall findings of the secondary review:

• With the appropriate equipment, LSVT-Loud can be administered using telepractice.

• For the most part, outcomes from 1-on-1 sessions and telepractice sessions are equivalent, cost effective, and result in positive P satisfaction.

• Although the reporting of the outcomes was somewhat vague, it is likely all or most of the outcomes improved listed in #2 following LSVT-Loud administered via telepractice.

• The authors provide several guidelines regarding the administration of LSVT-Loud using telepractice.

c. Were the results precise? Unclear. Information was not provided.

d. If confidence intervals 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? Not Applicable

e. Were the results of individual studies clearly displayed/presented? Variable

f. For the most part, were the results similar from source to source? Yes

g. Were the results in the same direction? Yes

h. Did a forest plot indicate homogeneity? Not Applicable

i. Was heterogeneity of results explored? No. Although the authors did note the type of P who is more likely to profit from LSVT-Loud, the recommendations were not based on statistical analysis.  

j. Were the findings reasonable in view of the current literature? Yes

           

                                                                                                                   

4. Were maintenance data reported? No.

 

SUMMARY OF INTERVENTION

 

Population:Parkinson’s Disease; Adult

 

Prosodic Targets:

• sound pressure level

• pitch range (acoustic and/or perceptual)

• loudness level

• loudness variability

• duration

Nonprosodic Targets:

• breathiness

• voice quality

• oromotor skills

• articulatory precision

• intelligibility

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: Loudness, duration

 

Description of Procedure—LSVT-Loud via teleconference

 

  • Technology: audiorecorder; equipment that can measure SPL, frequency and duration; access to Internet videoconferencing. Authors reference technology that has been developed to facilitate LSVT-Loud telepractice.

 

• Stimuli: written material; audiorecoding and playback; equipment that can measure SPL, frequency and duration.

 

• LSVT-Loud procedures were not described in the paper. The authors noted the incorporation of the following into LSVT-Loud: motor learning, skill acquisition, and exercises designed to facilitate neural plasticity. In addition, independent homework/carryover activities were required components.

 

• C focuses on increasing loudness and improving P’s perception of his/her loudness.

 

• Dosage = 50-60 minutes, 4 times a week, 4 weeks

 

• When treatment is terminated, P is expected to continue homework exercises.

 

 


Pennington et al. (2009)

April 30, 2014

SECONDARY REVIEW CRITIQUE

 

Note: Brief summaries of the interventions concerned with treating prosody or using prosody to treat other outcomes can be accessed by scrolling about two-thirds of the way down.

 

 

Source: Pennington L, Miller N, & Robson S. (2009). Speech therapy for children with dysarthria acquired before three years of age. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006937. DOI: 10.1002/14651858.CD006937.pub2

Reviewer(s): pmh

 

Date: April 30, 2014

 

Overall Assigned Grade: A (Highest possible grade based on the design is A+.)

 

Level of Evidence: A+

 

Take Away: Because the search revealed no experimental or quasi-experimental studies, some of the components of a Systematic Review were not completed. The authors did review 10 observational sources that provided some level of evidence but only six were clearly concerned with prosody. The SR noted that treating certain aspects of prosody may result in improved intelligibility, certain aspects of voice quality, and articulation. Only the prosody related critiques were reviewed below.

 

What type of secondary review? Classic Systematic Review

 

1. Were the results valid? Yes

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

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

c. Authors noted that they reviewed the following resources:

• conference proceedings

• hand searches

• internet based databases    

d. Did the potential sources involve only English language publications? No, sources could be in any language

e. Did the potential sources include unpublished studies? Yes

f. Was the time frame for the publication of the sources sufficient? Yes

g. Did the reviewers identify the level of evidence of the sources?

Yes, the reviewers noted that all reviewed sources did not meet inclusion criteria as they were observational investigations

h. Did the reviewers describe procedures used to evaluate the validity of each of the sources? Yes

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

j. Did the reviewers or review teams rate the sources independently? Yes

k. Were interrater reliability data provided? Yes

l. What was the interrater reliability for exclusion of the 10 sources? 100%

m. If there were no interrater reliability data, was an alternate means to insure reliability described? Not Applicable

n. Were assessments of sources sufficiently reliable? Not Applicable

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

p. Did the sources that were evaluated involve a sufficient number of participants? Yes, but these were for sources that were excluded from the Systematic Review.

q. Were there a sufficient number of sources? No

2. Description of outcome measures:

• Outcome Fox (2005): To improve

– sound pressure level (SPL),

– maximum duration,

– maximum and minimum pitch in HZ,

– pitch range in HZ,

– harmonics to noise ratio (HNR)

– C’s preference for loudness

– C’s preference for loudness variability

– C’s preference of overall pitch

– C’s preference for pitch variability

– C’s preference for articulatory precision

– C’s preference for overall voice quality

• Outcome Fox (2008): To improve

– sound pressure level (SPL),

– harmonics to noise ratio (HNR)

– jitter

– duration in maximum duration and sentence repetition tasks

– Parents’ preference for voice quality

• Outcomes for Pennington (2006): To improve

– intelligibility

– P’s perception of acceptability of the intervention

• Outcome for Pennington (2009): To improve

– intelligibility

– P’s perception of acceptability of the intervention

• Outcome for Puyuelo (2005): To improve measures of

– voice control

– intelligibility

– respiration

– articulation

– prosody

• Outcome for Robson (2009): To improve

– perception of severity of voice impairment

– harmonics to noise ratio

– jitter

– shimmer

– mean fundamental frequency

– rate with pauses

– rate without pauses

– time with pauses

– time without pauses

 

 

3. Description of results:

a. What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? No EBP metrics were provided

b. Summarize overall findings of the secondary review:

• The reviewers found no research meeting the criteria which included experimental and quasi-experimental designs (i.e. controlled studies).

• The review of the observational studies revealed that focusing on certain aspects of prosody may result in improved intelligibility, certain aspects of voice quality, and articulation. However, these results need to be verified using more rigorous research designs.

c. Were the results precise? Unclear

d. If confidence intervals 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? Not Applicable

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

f. For the most part, were the results similar from source to source? Yes

g. Were the results in the same direction? Yes

h. Did a forest plot indicate homogeneity? Not

i. Was heterogeneity of results explored? No

j. Were the findings reasonable in view of the current literature? Yes

k. Were negative outcomes noted? Yes

                                                                                                                   

4. Were maintenance data reported?Yes. The reviewers noted whether or not maintenance data were collected, although the outcomes were not always reported in the Systematic Review. When maintenance results were reported, the findings were inconsistent.

 

 

SUMMARY OF INTERVENTION

 

Population:Cerebral Palsy, Dysarthria; Child

 

Prosodic Targets:

– sound pressure level (SPL),

– maximum duration,

– maximum and minimum pitch in HZ,

– pitch range in HZ,

– C’s preference for loudness

– C’s preference for loudness variability

– C’s preference of overall pitch

– C’s preference for pitch variability

– duration in maximum duration and sentence repetition tasks

– prosody

– mean fundamental frequency

– rate with pauses

– rate without pauses

– time with pauses

– time without pauses

 

Nonprosodic Targets:

– harmonics to noise ratio (HNR)

– C’s preference for articulatory precision

– C’s preference for overall voice quality

– jitter

– Parents’ preference for voice quality

– intelligibility

– P’s perception of acceptability of the intervention

– voice control

– respiration

– articulation

– perception of severity of voice impairment

– harmonics to noise ratio

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: rate, loudness, prosodic contrasts (not defined), intonation, pausing, rhythm, duration

 

 

Description of Procedure associated with Fox (2005):

• Outcome: To improve

Acoustic Measures

– sound pressure level (SPL),

– maximum duration,

– maximum and minimum pitch in HZ,

– pitch range in HZ,

– harmonics to noise ratio (HNR)

Perceptual Measures

– C’s preference for loudness

– C’s preference for loudness variability

– C’s preference of overall pitch

– C’s preference for pitch variability

– C’s preference for articulatory precision

– C’s preference for overall voice quality

• The intervention involved administration of Lee Silverman Voice Therapy Loud.

 

Evidence Supporting Procedure associated with Fox (2005)

– Improvement in all acoustic outcomes for 3 of the 4 Ps who received treatment. This improvement was maintained at follow-up.

– With the exception of overall pitch, therapists preferred the post treatment perceptual measures.

 

 

Description of Procedure associated with Fox (2008):

• OUTCOME: To improve

– sound pressure level (SPL),

– harmonics to noise ratio (HNR)

– jitter

– duration in maximum duration and sentence repetition tasks

– Parents’ preference for voice quality

• The intervention involved administration of Lee Silverman Voice Therapy Loud.

 

Evidence Supporting Procedure associated with Fox (2008)

– Improvement in SPL in sustained vowels (post therapy and follow-up) and in sentences (after therapy)

– Improvements in jitter (post therapy and follow-up)

– After therapy, parents rated their children’s voices as “louder”, less “nasal” and more “natural”.

 

Evidence Contraindicating Procedure associated with Fox (2008)

– Analyzers were not blinded.

 

 

Description of Procedure associated with Pennington (2006):

• OUTCOME: To improve

– intelligibility

– P’s perception of acceptability of the intervention

• The investigators employed asystems approach to intervention focusing on breath control for speech and prosodic contrasts. These terms were not described in the Systematic Review.

 

Evidence Supporting Procedure associated with Pennington (2006)

• 4 of the 6 Ps improved single intelligibility post therapy but not at follow-up.

• 3 of 6 Ps improved connected speech intelligibility post therapy but not at follow-up.

• 3 of the 6 Ps perceived duration and intensity of the intervention to be acceptable

Evidence Contraindicating Procedure associated with Pennington (2006)

• No control group.

 

 

Description of Procedure associated with Pennington (2009):

• OUTCOME: To improve

– intelligibility

– P’s perception of acceptability of the intervention

• The investigators used a systems approaching targeting the stabilization of respiration, phonatory effort, speech rate, and phrase length or syllables per breath.

 

Evidence Supporting Procedure associated with Pennington (2009)

• 15 of the 16 Ps improved intelligibility.

• All P reported satisfaction with the intervention procedures.

 

Evidence Contraindicating Procedure associated with Pennington (2009)

•  No treatment fidelity treatment.

• No maintenance data.

 

 

Description of Procedure associated with Puyuelo (2005):

• OUTCOME: To improve measures of

– voice control

– intelligibility

– respiration

– articulation

– prosody

• There were 2 blocks of therapy:

Block1. Improving motor control by focusing on articulation, chewing, and expiratory breathing. (This was not successful.)

Block2. Improving control of exhalation for speech, coordinating exhalation and phonation, voice training, and prosody (intonation, pause, rhythm, and duration). Parents were also involved in this block (speech stimulation activities and use of narratives).

 

Evidence Supporting Procedure associated with Puyuelo (2005)

• Block 1 yielded improvement only in voice control.

• In Block 2 resulted in improvement of

– respiration

– voice

– articulation

– intelligibility

– prosody

 

Evidence Contraindicating Procedure associated with Puyuelo (2005)

• Long duration of intervention.

• Block 1 yielded improvement only in voice control.

• No control group.

• Data analyzers were not blinded.

 

 

Description of Procedure associated with Robson (2009):

• OUTCOME: To improve

– perception of severity of voice impairment

– harmonics to noise ratio

– jitter

– shimmer

– mean fundamental frequency

– rate with pauses

– rate without pauses

– time with pauses

– time without pauses

• The investigators used a systems approaching targeting the stabilization of respiration, phonatory effort, speech rate, and phrase length or syllables per breath.

 

Evidence Supporting Procedure associated with Robson (2009)

• The investigators reported

– Limited decrease in fundamental frequency,

– Limited decrease in intensity

– Limited decrease in jitter of children’s voices.

– Limited increase in speaking time between pauses.

 

Evidence Contraindicating Procedure associated with Robson (2009)

• The investigators did not find a change in perceived severity of voice impairment.

• No maintenance data.

 


Solomom et al. (2001)

April 23, 2014

EBP THERAPY ANALYSIS for

Single Subject Designs

 

Note: The summary can be viewed by scrolling about two-thirds of the way down on this page.

 

SOURCE: Solomon, N. P., McKee, A. S., & Garcia-Barry, S. (2001). Intensive voice treatment and respiration treatment for hypokinetic-spastic dysarthria after traumatic brain injury. American Journal of Speech-Language Pathology, 10, 51-64.

 

REVIEWER(S): pmh

 

DATE: April 22, 2014

 

ASSIGNED OVERALL GRADE: D+(This was a case study; therefore, the highest possible grade was D+.)

 

TAKE AWAY: This thorough case study provides guidance about use of Lee Silverman Voice Treatment (LSVT) and Combination therapy (LSVT plus Respiration therapy and Physical therapy) with a P with hypokinetic and spastic dysarthria as the result of traumatic brain injury (TBI). Some measures of breathing, intelligibility, and sound pressure level (SPL) improved.

                                                                                                           

 

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

                                                                                                           

 

2. What type of evidence was identified?                              

a. What type of single subject design was used? Case Studies- Description with Pre and Post Test Results    

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

                                                                                                           

3. Was phase of treatment concealed?

a. from participants? No

b. from clinicians? No

c. from data analyzers? Yes, perceptual measures were randomly presented to data analyzers (judges).

 

4. Was the participant adequately described? Yes, the description of the P was very thorough.

a. How many participants were involved in the study? List here: 1

 

b. The following characteristics/variables were described:

• age: ~ 25 years

• gender: m

• cognitive skills: intact attention and executive skills; 6th to 13th percentile on subtests of the Woodcock & Johnson Tests of Cognitive Ability-Revised; memory was moderately impaired

• receptive language: auditory and reading comprehension impairments

• etiology: Traumatic Brain Injury                         

• damage: “diffuse edema, small amounts of subarachnoid blood around the interpeduncular cistern, and punctate hemorrhages throughout the cortical white matter” (p. 52)

• coma: yes, started to regain consciousness at 1 month post-accident,

• previous therapy: received treatment until investigation began

 

c. Were the communication problems adequately described? Yes

• List the disorder type(s): hypokinetic-spastic dysarthria

• Other aspects of communication that were described included

Intelligibility: 40% in conversations with unfamiliar listeners; 50% in group therapy

hearing: within normal limits

oral motor skills:

• facial drooped on right side when at rest

• reduced range of motion for lips on right side

• reduced lip resistance

• reduced bilateral range of motion for tongue

– speech skills:

• diadochokinetic rate: rapid, blurred

• voice quality: breathy, rough, decreased loudness, monopitch, monoloudness

• imprecise consonant production

• resonance: slightly hypernasal

• prosody: slow, short rushes of rapid speech, long pauses

– pulmonary function:

• obstruction ruled out but forced vital capacity (FVC) was 54% of expectation

• slow vital capacity: 70% of expected value; problems with inspiration and expiration.

• chest wall kinematics: atypical at rest, reading, and in monologues.

                                                                                                                       

 

5. Was membership in treatment maintained throughout the study? Not applicable           

a. If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable

b. Were any data removed from the study? No

 

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

a. Were preintervention data collected on all behaviors? Yes

b. Did intervention data include untrained data? Yes

c. Did intervention data include trained data? No

d. Was the data collection continuous? Yes

e. Were different treatment counterbalanced or randomized? No

 

7. Were the outcomes measure appropriate and meaningful? Yes

a. The outcomes were

OUTCOME #1: to improve vital capacity

OUTCOME #2: to improve chest wall kinematics

PERCEPTUAL MEASURES

OUTCOME #3: to improve intelligibility in words and in sentences

OUTCOME #4: to Improve ratings of vocal roughness in reading and in monologues

OUTCOME #5: to improve ratings of vocal press (breathy to strained) in reading and in monologues

OUTCOME #6: to improve ratings of intonation (monotone to excessive variation) in reading and in monologues

OUTCOME #7: to improve ratings of loudness in reading and in monologues

ACOUSTIC MEASURES

OUTCOME #8: to improve sound pressure level (SPL) in reading and in monologues

OUTCOME #9: to improve speaking fundamental frequency (SF0) in reading and in monologues

OUTCOME #10: to improve the number of syllables produced per breath in reading and in monologues

OUTCOME #11: to improve interpause speech rate in reading and in monologues

 

b. The outcomes that are subjective are

• OUTCOME #3 (to improve intelligibility in words and in sentences)

• OUTCOME #4 (to Improve ratings of vocal roughness in reading and in monologues)

• OUTCOME #5 [to improve ratings of vocal press (breathy to strained) in reading and in monologues]

• OUTCOME #6 [to improve ratings of intonation (monotone to excessive variation) in reading and in monologue]

  • OUTCOME #7 (to improve loudness in reading and in monologues)

                                                       

c. List numbers of the outcomes that are objective:

• OUTCOME #1 (to improve vital capacity)

• OUTCOME #2 (to improve chest wall kinematics)

• OUTCOME #8 [to improve sound pressure level (SPL) in reading and in monologues]

• OUTCOME #9 [to improve speaking fundamental frequency (SF0) in reading and in monologues]

  • OUTCOME #10 (to improve the number of syllables produced per breath in reading and in monologues)

• OUTCOME #11 (to improve interpause speech rate in reading and in monologues)

 

d. The outcome measures that have supporting reliability data are

• OUTCOME #3 (to improve intelligibility in words and in sentences)

• OUTCOME #4 (to improve ratings of vocal roughness in reading and in monologues)

• OUTCOME #5 [to improve ratings of vocal press (breathy to strained) in reading and in monologues]

• OUTCOME #6 [to improve ratings of intonation (monotone to excessive variation) in reading and in monologue]

  • OUTCOME #7 (to improve loudness in reading and in monologues)

                       

e. Tthe data supporting reliability is

• The overall intraclass correlation coefficient for Outcomes 3 through 7 was 0.837.

 

 

8. Results:

a. Did the target behavior improve when it was treated? Yes, but it was Inconsistent as most but not all of the outcomes improved following either LSVT and/or Combination therapy.

b.   The overall quality of improvement for the different outcomes was

OUTCOME #1: to improve vital capacity: moderate improvement

OUTCOME #2: to improve chest wall kinematics: limited improvement

PERCEPTUAL MEASURES

OUTCOME #3: to improve intelligibility in words and in sentences: ineffective for LSVT and limited for Combination treatment

OUTCOME #4: to Improve ratings of vocal roughness in reading and in monologues: ineffective

OUTCOME #5: to improve ratings of vocal press (breathy to strained) in reading and in monologues: limited improvement for LVST and ineffective for Combination

OUTCOME #6: to improve ratings of intonation (monotone to excessive variation) in reading and in monologues: ineffective

OUTCOME #7: to improve ratings of loudness in reading and in monologues: limited improvement for LSVT but contraindicated for Combination Treatment

ACOUSTIC MEASURES:

OUTCOME #8: to improve sound pressure level (SPL) in reading and in monologues: moderate improvement (

OUTCOME #9: to improve speaking fundamental frequency (SF0) in reading and in monologues: ineffective

OUTCOME #10: to improve the number of syllables produced per breath in reading and in monologues: ineffective

OUTCOME #11: to improve interpause speech rate in reading and in monologues: limited

 

9. Description of baseline:

a. Were baseline data provided? Yes. Each outcome has one baseline data point.

b. Was baseline low (or high, as appropriate) and stable? (The numbers should match the numbers in item 7a.) NA

c. What was the percentage of nonoverlapping data (PND)? NA

 

 

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

 

 

11. Was information about treatment fidelity adequate? Not Provided

 

 

12. Were maintenance data reported?Yes. Maintenance data were elicited for Outcomes 3-11 about 3 months after the termination of therapy. In some cases, gains were maintained (e.g., SPL, intelligibility, some resting breathing measures, some speech breathing), in others it was reversed.

 

 

13. Were generalization data reported?Yes. The investigators added an additional 10 week course of Combination treatment to facilitate generalization. Gains were generally maintained. (See the Major Components section of the Summary for a description of the procedures.)

 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D+

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: to investigate the effectiveness of LSVT and Combination treatment on speech and breathing outcomes for a P with hypokinetic-spastic dysarthria that was the result of traumatic brain injury.

 

POPULATION: Traumatic Brain Injury; Hypokinetic-Spastic Dysarthria; Adult

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, intonation (range), pausing, rate

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness

 

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: breathing, voice quality, intelligibility

 

DOSAGE: 3 phases: (1) LSVT Phase, 1 hour sessions, 4 days a week, 4 weeks; (2) Combination Treatment Phase, 1 hour sessions, 4 days a week, 6 weeks; (3) Facilitate Carry Over Phase—1 hour of Combination Treatment per week for 10 weeks

 

ADMINISTRATOR: SLP; during Combination Therapy, P also received treatment from a Physical Therapist (PT)

 

MAJOR COMPONENTS:

 

– 3 phases:

 

1. LSVT PHASE

• C administered LSVT using the standard procedures

 

2. COMBINATION TREATMENT PHASE

• 1 day a week, P received only LSVT and 3 days a week he received a combination of LSVT and respiration treatment. C administered respiration treatment administered during the first ½ of the session and included respiration improvement techniques and cues during LSVT.

• C administered LSVT using standard procedures

• P (and the PT during PT sessions) administered treatments to improve the function of the upper chest wall. Respiration treatment included

– torso-extension stretches (SLP and PT)

– towel and corner stretches (PT)

– maximal inhalation and exhalation against resistance (SLP)

– expiration exercises with visual feedback (SLP)

– homework

 

3. FACILITATE CARRY OVER PHASE

• C administered Combination Treatment procedures 1 time a week.

• P completed homework activities 3 times a week

• C also administered ½ hour of therapy focusing on the use of a planner and completing tasks each week.

• P did not receive PT during this phase.