Chenausky & Schlag (2018)

April 29, 2018

EBP THERAPY ANALYSIS

Treatment Groups 

Note: Scroll about 80% of the way down the page to read the summary of the procedure.

 Key:

AMMT =  Auditory-motor mapping training

approximately correct =  P produced consonant bisyllable target with 2 of 3

features (manner, place, voicing)  of an adult form of the consonant AND the

vowel portion of the bisyllable target was of the same class (i.e., same height

and degree of backness)

ASD =  Autism Spectrum Disorder

C = Clinician

EBP = evidence-based practice

f = female

m = male

MV =  Minimally Verbal

NA = not applicable

P = Patient or Participant

pmh =  Patricia  Hargrove, blog developer

SLP = speech–language pathologist

SRT =  Speech Repetition Therapy

 

 

SOURCE: Chenausky, K. V., & Schlaug, G. (2018). From intuition to intervention: Developing an intonation-based treatment for autism.  Annals of the New York Academy of Sciences, 1-13. doi: 10.1111/nyas. 13609 (Early Online Version before inclusion in an issue)

 

 

REVIEWER(S):  pmh

 

DATE:   April 24, 2018

 

ASSIGNED GRADE FOR OVERALL QUALITY: 

– Proof of Concept Study =  C-

– Replication Study =  C-

– Comparison Study =  B-

 

TAKE AWAY: Although the article provides information that could be used as a summary of stages of program assessment, the focus of this review is limited to the evidence for the effective of a music-based intervention: Auditory-motor mapping training (AMMT.) Three studies were reported in this investigation:  Proof of Concept, Replication, and Comparison. Some participants’ data were used in more than one investigation. Each of the studies is reviewed separately and indicate that AMMT has potential for success.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence?

     – Prospective, Nonrandomized Group Design with Controls?   Comparison Study

– Prospective, Single Group with Pre- and Post-Testing  Proof of Concept Study, Replication Study

 

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

     – Proof of Concept Level = C+

     – Replication Level = C+

     – Comparison Level = B+

 

PROOF OF CONCEPT STUDY

                                                                                                           

  1. Group membership determination:

                                                                                                           

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

 

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

 

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants?No
  • from clinicians? No
  • from analyzers? Yes

                                                                    

 

  1. Was the group adequately described? No

 

–  How many  Ps were involved in the study?

  • total # of Ps:   6
  • # of groups:  1

 

–  CONTROLLED CHARACTERISTICS

  • expressive vocabulary:less than 20 words
  • imitation skills: able to imitate at least 2 sounds
  • diagnosis:Minimally Verbal (MV) Autism Spectrum Disorder (ASD)
  • other diagnoses:excluded sensorineural disorders (e.g., deafness, Down syndrome)

 

–  DESCRIBED CHARACTERISTICS

  • age:5 years 9 months to  8 years 9 months (mean = 6 years 7 months)
  • gender: 1f; 5m

 

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

                                                         

–  Were the communication problems adequately described?  No

  • disorder type:  MV ASD
  • functional level:  baseline phonetic inventory =  7.9 (+/- 5.3)

 

 

  1. Was membership in the group 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. Was the group controlled acceptably?  No, this was a single group study.

 

 

  1. Was the outcome measure appropriate and meaningful? Yes

 

  • OUTCOME #1:Percentage of “syllables approximately correct” (p. 4)  from a list of 30 bisyllable words/phrases

 

NOTE:  approximately correct =  P produced consonant bisyllable target with 2 of 3 features (manner, place, voicing)  of an adult form of the consonant AND the vowel portion of the bisyllable target was of the same class (i.e., same height and degree of backness)

 

  • The outcome measures was subjective.

 

*  The outcome measure was NOTobjective.

                                         

 

  1. Were reliability measures provided?

                                                                                                             

  • Interobserver for analyzers?Yes

    –  OUTCOME #1:  Percentage of “syllables approximately correct” (p. 4)  from a list  of 30 bisyllable words/phrases

–  for the measure “approximately correct”

            ∞ percent of interobserver agreement was 68%

            ∞ difference in from change agreement–  Cohen’s K = 0.55 (p <

                0.0005)

            ∞ investigators claimed these measures were “favorable” (p. 5) and

                 “at least ‘moderate’ or ‘good’)

 

  • Intraobserver for analyzers?No 

 

  • Treatment fidelity for clinicians? No , but the investigators developed a manual describing treatment procedures.

 

 

  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

 

 

PRE AND POST TREATMENT ONLY ANALYSES

 

 

  • OUTCOME #1:Percentage of “syllables approximately correct” (p. 4)  from a list of 30 bisyllable words/phrases:  Ps scores were significantly better following treatment compared to pretreatment data

 

  • What was the statistical test used to determine significance?

–  t-test

     –  binominal test of significant

 

  • Were confidence interval (CI) provided?Yes

     –  95% CI:  xxx, investigators reported that the Ps pretreatment scores were beyond the 95% CI for the post intervention scores.

 

 

  1. What is the clinical significanceNo EBP data provided but investigators claim clinical significance by describing the increase of percentage of approximately correct bisyllables.

 

 

  1. Were maintenance data reported?No

 

 

  1. Were generalization data reported?No, but the outcome measure included trained and untrained stimuli but the trained/untrained data were not presented separately.

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • Six Ps were selected to determine if AMMT regularly resulted in improvements in the outcome.

 

  • The 6 Ps each participated in 40 treatment sessions and served as his/her control.

 

  • The investigators performed multiple baseline assessment of the outcome and used the best performance of each P as his/her baseline.

 

  • Following the 10thsession and every 5 sessions after the 10th, the investigators performed an assessment or probe session. Probe sessions were similar to the treatment session except they included both trained and untrained (generalization) stimuli.

 

  • Each Ps’ clinician (C) administered the probes but the ratings of correct/incorrect were performed by a blinded rater.

 

 

GRADE= C-

 

 

REPLICATION STUDY

 

 

  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. Was the group adequately described? No

 

– How many  Ps were involved in the study?

  • total # of Ps: 17
  • # of groups:1

 

–  CONTROLLED CHARACTERISTICS

  • expressive vocabulary:less than 20 words
  • imitation skills: able to imitate at least 2 sounds
  • diagnosis:Minimally Verbal (MV) Autism Spectrum Disorder (ASD)
  • other diagnoses:excluded sensorineural disorders (e.g., deafness, Down syndrome)

 

–  DESCRIBED CHARACTERISTICS

  • age:3 years; 5 months to 9 years; 8 months (mean =6 years; 6 months)
  • gender:2f; 15m

 

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

                                                         

–  Were the communication problems adequately described?  No

  • disorder type: MV ASD
  • functional level: baseline phonetic inventory:  mean = 7.2 (+/- 4.3)

 

 

  1. Was membership in the group 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 a single group.

 

 

  1. Was the outcome measure appropriate and meaningful? Yes

 

  • OUTCOME #1:Percentage of “syllables approximately correct” (p. 4)  from a list of 30 bisyllable words/phrases

 

  • The outcome measures was subjective.
  • The outcome measure was NOTobjective.

                                         

 

  1. Were reliability measures provided?

                                                                                                             

  • Interobserver for analyzers?No, but see the results for interobserver reliability for the Proof of Concept study.

 

  • Intraobserver for analyzers?No 

 

  • Treatment fidelity for clinicians?Yes

–  All of the reviewed sessions included the major AMMT components (intoned speech) and drums.

 

 

  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

 

PRE AND POST TREATMENT ONLY ANALYSES

 

OUTCOME #1:  Percentage of “syllables approximately correct” (p. 4)  from a list  of 30 bisyllable words/phrases imitated

  • There post treatment scores were significantly better than thepretreatment score.
  • The investigators compared the results of the Replication Group and the Proof of Concept Group at 25 sessions and determined

∞  that there was no significant difference between the groups,

∞  that their combined outcomes were significantly better after treatment, and

∞  that the trajectories of their improvement were similar

∞  overall the number of correct syllables in the combined groups was about 15 at baseline and 27 following 25 sessions.

 

 

—  What was the statistical test used to determine significance?

  • t-test
  • ANOVA

 

–  Were confidence interval (CI) provided?  No

 

 

  1. What is the clinical significance(List outcome number with data with the appropriate Evidence Based Practice, EBP, measure.) No 

 

 

  1. Were maintenance data reported?No

 

 

  1. Were generalization data reported?No, treated bisyllables were included in the assessment data but they were not described separately.

 

 

  1. Describe briefly the experimental design of the investigation.
  • Seventeen Ps were selected to determine to replicate the finding of the Proof of Concept study with a larger group.

 

  • The 17 Ps each participated in 25 treatment sessions and served as his/her control. The 25 sessions dosage is markedly reduced from the Proof of Concept study but was used because of the burden of 40 sessions for families. The decision also was made to use 25 sessions because almost 90% of the change in the Proof of Concept study had been achieved by session 25.

 

  • The investigators performed multiple initial preintervention assessments of the outcome and used the best performance of each P as his/her baseline.

 

  • Following the 10thsession and every 5 sessions after the 10th, the investigators performed an assessment or probe session. Probe sessions were similar to the treatment sessions except they included both trained and untrained (generalization) stimuli. Each Ps’ clinician (C) administered the probes but the ratings of correct/incorrect were performed by a blinded rater.

 

  • The investigators combinedthe data from the Ps in the Proof of Concept and the Replication studies because the performance of the 2 groups was similar.

 

GRADE C-

 

 

COMPARISON STUDY

 

  1. Group membership determination:

                                                                                                           

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

 

  • If there were groups andthe Ps were not randomly assigned to groups, were members of groups carefully matched?  Yes
  • -Seven Ps from the original Ps in the Replication study were matched to 7 Ps who were to be assigned to the control group, Speech Repetition Therapy (SRT.)

     –  The Ps were matched on the basis of

∞  chronological age

∞  mental age

∞  baseline phonemic (phonetic) repetition ability

                                                                    

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No
  • from clinicians? No
  • from analyzers? Yes

                                                                    

 

  1. Were the groups adequately described? No

 

–  How many  Ps were involved in the study?

  • total # of Ps: probably
  • # of groups:2
  • List names of groups and the # of participants in each group:

     –  AMMT = 7  (a subgroup of Ps from the AMMT treated Replication study)

–  SRT = 7

 

–  CONTROLLED CHARACTERISTICS

  • expressive vocabulary:less than 20 words
  • imitation skills: able to imitate at least 2 sounds
  • diagnosis:Minimally Verbal (MV) Autism Spectrum Disorder (ASD)
  • other diagnoses:excluded sensorineural disorders (e.g., deafness, Down syndrome)

 

–  DESCRIBED CHARACTERISTICS

  • age:

     –  AMMT = 3 years; 5 months to 8 years; 11 months (mean =  6 years, 1 month)

     –  SRT =  3 years; 9  months to 8 years; 5 months (means = 5 years; 8 months)

  • gender:

     –  AMMT = 7m

     –  SRT = 2f; 5m

 

–   Were the groups similar before intervention began? Yes

                                                         

–  Were the communication problems adequately described?  No 

  • disorder type: (List) MV  ASD
  • functional level: baseline phonetic inventory

– AMMT =  7.1 (+/- 3.4)

– SRT =  8.9 (+/- 5.4)

 

 

  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? No 

 

 

  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 foil/comparison and the target groups constant? Yes

 

 

  1. Was the outcome measure appropriate and meaningful? Yes

                                                                                                             

  • OUTCOME #1:Percentage of “syllables approximately correct” (p. 4)  from a list of 30 bisyllable words/phrases

 

  • The outcome measure was subjective.
  • The outcome measure was NOT objective.

                                         

 

  1. Were reliability measures provided?

                                                                                                             

  • Interobserver for analyzers?No, but see the results for interobserver reliability for the Proof of Concept study.

 

  • Intraobserver for analyzers?No 

 

  • Treatment fidelity for clinicians?Yes

     – Every AMMT reviewed trial reviewed contained the 2 major components of AMMT:  intoned speech and drumming.

     – None of the SRT  trials reviewed contained the 2 major components of AMMT: intoned speech and drumming.

 

 

  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 AND FOIL/COMPARISON/NO TREATMENT GROUP ANALYSES

 

  • OUTCOME #1:  Percentage of “syllables approximately correct” (p. 4)  from a list  of 30 bisyllable words/phrases

–  Overall, both the AMMT and the SRT groups improved significantly from baseline to the end of treatment.

     –  The 2 groups (AMMT, SRT) scores were not significantly different from one another over the 4 testing periods.

 

  • What was the statistical test used to determine significance? ANOVA

 

  • Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significanceNA

 

 

  1. Were maintenance data reported? Yes  __x__  No ______
  • Improvements following treatment of 25 weeks were maintained 4 and 8 weeks post treatment.(That is, there no significant difference between outcomes immediately after treatment and 4 and 8 weeks post treatment.

 

  • There were no significantly different outcome scores for the 2 groups .

 

 

  1. Were generalization data reported?Yes

 

  • Trained stimuli were significantlymore likely to be correct than untrained stimuli.

 

  • There were no significantly different outcome scores for the 2 groups .

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • The investigators matched 7 of the Ps from the Replication study to a group of Ps who received SRT.

 

  • The 14 Ps each participated in 25 treatment sessions and served as his/her control.

 

  • The investigators compared the outcomes of the AMMT and SRT groups following 25 sessions and analyzed the data.

 

  • For the maintenance analysis, the investigators then selected 10 AMMT Ps for the Replication study and the 7 SRT Ps from this Comparison study and compared their performance 4 and 8 weeks following the termination of treatment.

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  B-

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To determine if a music-based intervention (AMMT), based on Melodic Intonation Therapy, warrants additional research

 

POPULATION:  ASD

 

MODALITY TARGETED:  production

 

 

ELEMENTS OF PROSODY USED AS INTERVENTION:  music (rhythm, intonation, pitch), rate.

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: Articulation

 

DOSAGE:  45 minute individual sessions for 40 (Proof of Concept study) or 25 sessions (Replication study or Comparison study)

 

ADMINISTRATOR:  probably SLP

 

 

MAJOR COMPONENTS:

 

  • Two treatments were described in the article:AMMT and SRT

 

 

AUDITORY-MOTOR MAPPING TRAINING (AMMT)

 

  • AMMT is derived from Melodic Intonation Therapy.

 

  • The main objective of AMMT is to increase speech sound accuracy and intelligibility.

 

  • AMMT involves scaffolding, massed practice, spaced practice, and several behavioral management techniques.

 

  • Clinicians (Cs) model intoned bisyllables at 1 syllable per second using 2 pitch levels that corresponded to naturalspeech. The C accompanied the production of the intoned bisyllables with tapping of an electronic drum using the same pitches as the intoned modeled bisyllables. Again, the rate is one tap per second.

 

  • There are 5 hierarchical steps in AMMT:

–  Listening:  The C produces a model of the bisyllable target word at the end of a sentence. Example: “It is fun to blow bubbles” (p. 6.)  The target was intoned using the 2 pitches and the intoning was accompanied the tapping of an electronic drum.

 

–  Unison: C and P produce the bisyllable target word together. Example:  C says: “Let’s say it together:  bubbles” (p. 6.) The target was intoned using the 2 pitches and the intoning was accompanied the tapping of an electronic drum.

 

–  Unison Fade: C says the first syllable of the bisyllable target word, cuing P to produce the whole target. Example:  C says: Again:  bu….”   (p. 6.) The target was intoned using the 2 pitches and the intoning was accompanied the tapping of an electronic drum.

 

–  Imitation: C models the target word and directs P to imitate. The target was intoned using the 2 pitches and the intoning was accompanied the tapping of an electronic drum. Example:

∞  C says: “My turn: bubbles.” (p. 6)

∞  C says: “You turn …..”  (p. 6)

 

–  Cloze: C elicits the independent production of the bisyllable target from P. Example: “Last time It’s fun to blow …..” (p. 6.).

 

  • Each session involved 15 bisyllable target words in which each was practiced 5 times before moving to the next target.

 

 

SPEECH REPETITION THERAPY  (SRT)

 

  • SRT used the same procedures at AMMT without the intoning and drumming.

 

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Mahoney (2015)

February 8, 2018

SECONDARY REVIEW CRITIQUE

NOTE: A summary of the reviewed prosody-based interventions can be viewed by scrolling about two-thirds of the way down this page.

KEY:

CAS = Childhood Apraxia of Speech

C = clinician

MIT = Melodic Intonation Therapy

NA = not applicable

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

SR = Systematic Review

VML = Verbal Motor Learning (VML)

 

 

Source: Mahoney. K. (2015). A narrative review of the intervention techniques for childhood apraxia of speech. Undergraduate Review, 11, 81-90. From the institutional repository of Bridgewater State University (Bridgewater, MA.) Retrieved from h7p://vc.bridgew.edu/undergrad_rev/vol11/iss1/15

 

Reviewer(s): pmh

 

Date: February 6, 2018

 

Overall Assigned Grade: C The highest possible Overall Assigned Grade is B which is based on the design of the investigation. The Overall Assigned Grade does not reflect a judgment regarding the quality of the intervention.

 

Level of Evidence: B (Systematic Review with Broad Criteria)

 

Take Away: Although the investigator reviewed 13 sources, only 5 involved prosody in the treatment protocols. These 5 will be the focus of this Secondary Review Critique. The results of the Systematic Review (SR) revealed that 3 of the 5 prosody based interventions resulted in significant improvement.

 

What type of secondary review? Narrative Systematic Review

 

 

  1. Were the results valid?

 

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

 

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

 

– The author of the secondary research noted that she reviewed the following resources: internet based databases and ASHA online journals

 

– Did the sources involve only English language publications? Yes

 

– Did the sources include unpublished studies? No

 

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

 

– Did the author of the secondary research identify the level of evidence of the sources? Yes

 

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

∞ The investigator included the following information in the review which was a replication of existing research (see p. 84)

  • reference for source
  • publication year
  • intervention description/categorization
  • number of participants (Ps)
  • age of Ps
  • description of service delivery strategy
  • duration of the intervention
  • Level of Evidence

 

– 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? Yes

 

– Interrater reliability data: 100% interrater agreement for the judgment of Level of Evidence

 

– 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? No

 

– Were there a sufficient number of sources? No, but this is the current status of literature.

 

  1. Description of outcome measures:

 

— The 5 sources that were concerned used prosody within the treatment protocol and their associated outcomes were

 

  • Outcome for Ballard et al. (2010): average duration for the first 2 syllable of real words

 

  • Outcome for Lagasse (2012): the outcomes were unclear

 

  • Outcomes for Martikainen & Korpilahti (2011): percentage of correct vowels and percentage of correct consonants

 

  • Outcomes McCabe et al. (2014): percentage of correct vowels, percentage of correct consonants, and percentage of correct stress patterns

 

  • Outcomes for Vashdi (2013): word length, vocal intensity, frequency

 

 

  1. Description of results:

 

  • What measures were used to represent the magnitude of the treatment/effect size?  Some of the non-prosodic treatments provided EBP measures, but none of the prosodic treatments provided EBP measures.

 

  • Summary of the findings of the secondary research:

 

– The results of the reviewed sources for treatments involving prosody

 

  • Ballard et al. (2010)

     ∞ The durations of the first 2 syllables of real words were significantly more “normalized” for all 3 Ps. (The statistical test was the Kruskal-Wallis Test.)

 

  • Lagasse (2012)

∞ The outcomes were not provided but it was noted that p was greater than 0.05 for comparisons using the Wilcoxon test.

 

  • Martikainen & Korpilahti (2011)

     ∞ For the percentage of correct vowels, there was a significant improvement for Melodic Intonation Therapy (MIT) training immediately following treatment.

     ∞   For the percentage of correct consonants, there was a significant improvement for Melodic Intonation Therapy (MIT) training 6 weeks after the termination of treatment.

     ∞ Statistical analysis involved the application of Generalized Cochran-Mantel-Haenszel Statistics for Repeated Measures.

 

  • McCabe et al. (2014)

Only raw data were provided by the authors of the source investigation, a summary of the data was not provided in the current SR.

 

  • Vashdi (2013)

Significant improvements were noted for word length (duration), intensity, and frequency. The statistical analysis involved the use of Paired t-tests.

 

  • Were the results precise? Unclear/Variable

 

  • 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? NA, confidence intervals were not provided.

 

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

 

  • For the most part, were the results similar from source to source? Yes, 4 of the 5 prosody related treatments claimed improvement.

 

  • Were the results in the same direction? Yes, for the most part. Four of the 5 prosody related treatments reported improvement.

 

  • Did a forest plot indicate homogeneity? NA

 

  • Was heterogeneity of results explored? No

 

  • Were the findings reasonable in view of the current literature? Yes
  • Were negative outcomes noted? No

           

                                               

  1. Were maintenance data reported? Yes, for one investigation.
  • Martikainen & Korpilahti (2011) : For the percentage of correct consonants, there was a significant improvement for Melodic Intonation Therapy (MIT) training 6 weeks after the termination of treatment.

 

  1. Were generalization data reported? No

 

 

SUMMARY OF INTERVENTIONS

 

NOTE: The treatment procedures, for the most part, were only named, and not described, in the Secondary Review

 

Ballard et al. (2010)

 

Population: CAS, Children, N = 3 (ages: 7;8 to 10;10)

 

Prosodic Targets: Duration

 

Description of Procedure/Source (Ballard et al., 2010)

  • Design: Single Subject Experimental Design: Multiple Baselines; Behaviors Across Ps (Level of Evidence IIb)
  • Administrator: Graduate Student in SLP, supervised
  • Dosage: individual sessions 50 minutes per session, 2 times a week for 8 weeks (16 sessions)
  • Procedures: enhanced intonation patterns

 

Evidence Supporting Procedure/Source (Ballard et al., 2010)

  • All Ps produced significantly more normalized durations for the first 2 syllables of real words.

 

==========

 

Lagasse (2012)

 

Population: CAS, Children, N = 2 (ages: 5, 6)

 

Prosodic Targets: Outcomes unclear

 

Nonprosodic Targets: Outcomes unclear

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: music (pitch/intonation, tempo, loudness)

 

Description of Procedure/Source Lagasse (2012)

 

  • Design: Single-Subject Design: AB (Level of Evidence: IIb)
  • Administrator: Music Therapist
  • Dosage: in the home, 40 minutes, 1 time a week, 4 weeks; Ps also received SLP services concurrently
  • Procedures: Melodic Intonation Therapy (MIT)

 

Evidence Contraindicating Procedure/Source Lagasse (2012)

  • None of the comparisons achieved significance.

 

======

 

Martikainen & Korpilahti (2011)

 

 

Population: CAS, Children, N = 1 (age: 4;7)

 

 

Nonprosodic Targets: vowels, consonants

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: music (pitch/intonation, tempo, loudness)

 

Description of Procedure/Source Martikainen & Korpilahti (2011)

  • Design: Single-Subject Experimental Design: ABA (Level of Evidence: IIb)
  • Administrator: SLP
  • Dosage: individual sessions, 30 minute sessions, 18 sessions per 6 week block
  • Procedures:

– Investigators administered 6 week long blocks of MIT and the Touch Cue Method. (Only MIT is reported in this review.) There was also a 6 week long withdrawal block and a follow up block.

 

Evidence Supporting Procedure/Source Martikainen & Korpilahti (2011)

– For the percentage of correct vowels, there was a significant improvement for Melodic Intonation Therapy (MIT) training immediately following treatment.

– For the percentage of correct consonants, there was a significant improvement for Melodic Intonation Therapy (MIT) training 6 weeks after the termination of treatment.

 

========

 

McCabe et al. (2014)

 

Population: CAS, Children, N = 4 (ages: 5;5-8;6)

 

Prosodic Targets: stress (lexical)

 

Nonprosodic Targets: consonants, vowels

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: stress (lexical)

 

Description of Procedure/Source McCabe et al. (2014)

  • Design: Single-Subject Design: AB (Level of Evidence: IIb)
  • Administrator: SLP
  • Dosage: individual sessions, 60 minutes, 4 times a weeks, 3 weeks (12 sessions)
  • Procedures: Administered ReST

Evidence Supporting Procedure/Source McCabe et al. (2014)

– Only raw data were provided by the authors of the sources, a summary of the data was not provided in the current investigation

 

Evidence Contraindicating Procedure/Source McCabe et al. (2014)

– Only raw data were provided by the authors of the sources, a summary of the data was not provided in the current investigation

====

 

Vashdi (2013)

 

Population: CAS, Children, N = 1 (age: 14)

 

Prosodic Targets: intensity, frequency, duration

 

Description of Procedure/Source Vashdi (2013)

  • Design: Case Study (Level of Evidence: III)
  • Administrator: Verbal Motor Learning (VML) Therapist
  • Dosage: individual sessions, 30 minute sessions, 1 time a week. 4 weeks
  • Procedures:

– Administered VML therapy paired with the Distal Dynamic Stabilization Technique

 

Evidence Supporting Procedure/Source Vashdi (2013)

  • Significant improvements were noted for word length (duration), intensity, and frequency.

 

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


Kim & Tomaino (2008)

January 29, 2018

EBP THERAPY ANALYSIS

Treatment Groups 

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

 Key:

C = Clinician

EBP = evidence-based practice

f = female

m = male

MT = music therapy

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE: Kim, M., & Tomaino, C. M. (2008.) Protocol evaluation for effective therapy for persons with nonfluent aphasia. Topics in Stroke Rehabilitation, 15, 555- 569.

 

REVIEWER(S): pmh

 

DATE: January 26, 2018

 

ASSIGNED GRADE FOR OVERALL QUALITY: C- (The highest possible grade based on the type of evidence is C. The Assigned Grade for Overall Quality is not a judgment regarding the quality of the intervention, it merely evaluates the type of research design and implementation.)

 

TAKE AWAY: Investigators reviewed music therapy (MT) describing the effectiveness of 7 MT techniques for improving articulation, fluency, prosody, and breath support for patients (Ps) with nonfluent aphasia.

 

 

  1. What type of evidence was identified?
  • What was the type of evidence? Qualitative Research involving Multiple Participants

                                                                                                          

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

 

                                                                                                           

  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? No

                                                                    

 

  1. Were the Ps adequately described? Yes

How many Ps were involved in the study?

  • total # of Ps: 7
  • # of groups: 1
  • List names of groups and the # of participants in each group:

 

– CONTROLLED CHARACTERISTICS

  • Diagnosis: Nonfluent Aphasia

 

– DESCRIBED CHARACTERISTICS

  • age: early 50s to early 70s
  • gender: 2m; 5f
  • cognitive skills:
  • 6 of the 7 Ps displayed intact cognitive skils;
  • 1 P had difficulty attending due to drowsiness associated with medications
  • motor skills: 6 of the 7 Ps were right hemiplegic
  • etiology: All Ps had experienced single or multiple strokes in the left hemisphere
  • post onset: 21 months to 21 years
  • social-emotional Status: the mood of the Ps was described as varied
  • comorbid medical issues:
  • chronic bronchitis 1
  • depression 1  
  • hypertension, high blood pressure 5  
  • diabetes 2
  • anemia 2  
  • coronary heart disease 1
  • renal artery stenosis 1  
  • congestive heart failure 1  
  • mild dementia 1

 

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

                                                         

– Were the communication problems adequately described? Yes

  • disorder type:
  • All Ps diagnosed with nonfluent aphasia.
  • In addition.

∞ 3 Ps were diagnosed with apraxia

∞ 1 P was diagnosed with dysarthria

∞ 2 Ps were diagnosed with dysphagia

∞ 2 Ps were diagnosed with fluent aphasia

∞ 1 P was diagnosed with receptive aphasia

 

  • functional level: severity ranged from mild/moderate to severe

 

 

  1. Was membership in groups maintained throughout the study?
  • Did the group maintain at least 80% of its 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

 

– OUTCOMES

  • OUTCOME #1: Articulation skills (accuracy rating)

 

  • OUTCOME #2: Fluency (words per utterance)

 

  • OUTCOME #3: Prosody (rating of rhythm and intonation)

 

  • OUTCOME #4: Breath support (number of syllables produced in sustained breath)

 

ALL the outcome measures were subjective.

 

– NONE of the outcome measures that were objective.

                                         

 

  1. Were reliability measures provided?
  • Interobserver for analyzers? No. However, the 66 videotapes were reviewed, described, and analyzed by 3 investigators. The data from these reviews were synthesized.

 

  • Intraobserver for analyzers?   No

 

  • Treatment fidelity for clinicians? NA _x__, the methodology involved a description and evaluation of treatment techniques used in music therapy with Ps with nonfluent aphasia. The purpose was not to investigate the effectiveness of a single program.

 

 

  1. Summary of the description of the results:

 

PRE AND POST TREATMENT ANALYSES

 

  • OUTCOME #1: Articulation skills (accuracy rating)— across music therapy techniques the gains for individual Ps ranged from 5% to 40%

 

  • OUTCOME #2: Fluency (words per utterance) across music therapy techniques the gains for individual Ps ranged from 5% to 65%

 

  • OUTCOME #3: Prosody (rating of rhythm and intonation) across music therapy techniques the gains for individual Ps ranged from 10% to 50%

 

  • OUTCOME #4: Breath support (number of syllables produced in sustained breath) across music therapy techniques the gains for individual Ps ranged from 0 to 5 syllables

 

– What was the statistical test used to determine significance? NA, differences were described and not subjected to inferential statistical analysis.

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significanceNA, evidence-based practice data were not provided.

 

 

  1. Were maintenance data reported? No

 

 

  1. Were generalization data reported? No

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • This qualitative research involved Protocol Evaluation in which the investigators reviewed 66 videos of MT sessions from 7 Ps with nonfluent aphasia.

 

  • The investigators identified 7 MT techniques from the literature that were used with the Ps and noted their effectiveness as well as recommended guidelines for employing each of the techniques.

 

  • The 7 MT techniques were

– Singing Familiar Songs

– Breathing into Single Syllable Sounds

– Dynamically Cued Singing

– Musically Assisted Speech

– Rhythmic Speech Cuing

– Oral Motor Exercise

– Vocal Intonation

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C-

 

 

SUMMARY OF INTERVENTION

 

 

PURPOSE: To describe and evaluate techniques used in MT with Ps with nonfluent aphasia and to link the findings to existing research.

 

POPULATION: Nonfluent Aphasia; Adults

 

MODALITY TARGETED: Production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: rhythm, intonation

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rhythm, intonation, loudness, rate, tempo, pause

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: articulation; breath support

 

DOSAGE: 8 to 12 individual sessions, 3 times a weeks, 4 weeks, about 30 minutes each session

 

ADMINISTRATOR: Music therapist.

 

MAJOR COMPONENTS:

 

 

 

  • The Clinician (C), a Music Therapist, administered the sessions in a quiet room.

 

  • The C administered 7 MT treatment techniques in each of the sessions:

– Singing Familiar Songs

– Breathing into Single Syllable Sounds

– Dynamically Cued Singing

– Musically Assisted Speech

– Rhythmic Speech Cuing

– Oral Motor Exercise

– Vocal Intonation

 

  • The 7 MT techniques had been derived from the existing literature and were included in the treatment of the speech and singing for Ps with nonfluent aphasia.

 

  • The sessions were recorded and then analyzed by a team of researchers who developed a description of each technique’s effectiveness and guidelines for application.

 

  • The investigators comments (summary, analyses, hints) for each of the seven techniques are listed below.

 

SINGING FAMILIAR SONGS

 

  • Description:

– C leads P in the singing of familiar songs.

– C directs P to select a favorite song.

– C and P focus on the most familiar parts of the song and repeatedly sing them.

– C assists P by modifying the tempo to match P’s skills.

– The investigators contend that modifications of tempo, loudness, and intonation can facilitate interactions between P and C.

 

  • Evidence: (see also Item #9 above)

– Six of the 7 Ps displayed improved articulation and rhythm while singing.

– Five of the Ps had “shallow” (p. 561) voice quality, this improved while singing familiar songs.

– Familiar songs and familiar portions of songs appear to increase motivation and performance.

EXAMPLE: P1

  • sang 80% of words correctly in the first verse of a familiar song and
  • during the second, less familiar, verse she sang only 60% of the words correctly and her loudness decreased 50%.
  • with practice during therapy, her performance on the second verse improved but did not reach the level of the first verse.

– The rhythm of the songs appear to facilitate articulatory accuracy.

EXAMPLE: P5

  • could not produce the words from a familiar song accurately in speech or even produce the rhythm even when cued by mouthing and/or tapping
  • in the context of singing the words P produced 80% of the words accurately and used the targeted rhythm

 

  • Hints:      

– Make sure the songs are familiar; do not improvise new songs.

– It is important to focus on the familiar portions of songs.

It is better to use songs that P knew premorbidly.

– To facilitate accurate production of rhythm and articulation while singing, C should modify the tempo to match P’s skills.

– C should provide cues (e.g., tapping, drum beating, up-down hand movement, mouthing, etc.) to facilitate P’s production.

– To improve the melody of a P’s singing, C should insure that when singing in unison with P, the C should not be too loud and at times let the Ps sing independently. Rather than rely solely on unison singing, P can model and then have C imitate singing.

– In severe cases, C may consider withholding the Musically Assisted Speech technique until P is successful with the Singing Familiar Songs technique.

 

 

BREATHING INTO SINGLE SYLLABLE SOUNDS

 

 

  • Description:

– P breathed single syllable sounds. This was achieved by having P exhale and gently vocalize speech sounds using the following hierarchy:

  • producing natural vocal sounds (e.g., yawning, throat clearing, sighing, etc.)
  • sighing vowels
  • producing vowels
  • producing bilabial consonants
  • producing alveolar consonants
  • producing velar consonants

 

  • Evidence: (see also Item #9 above)

– Articulatory accuracy increased when Cs introduced pauses between syllables.

– The addition of melody to this technique had equivocal results. EXAMPLE:

  • For one P the addition of a melody to the technique resulted in P humming rather than singing the targets.
  • Other Ps seemed to perform better when C intoned targeted syllables in unison with the P and then alternated between modeling and imitation.
  • Melody added to the stimuli was associated with more improved articulation accuracy when the singing involved tones that were disconnected (staccato) from one another rather than when they were sung with smooth transitions from one syllable to the next (in legato.) EXAMPLE:

– TWINKLE TWINKLE LITTLE STAR was associated with better articulation accuracy than AMAZING GRACE.

 

  • Hints:

— The hierarchy of targets speech sound to vocalize is a guideline. Cs should adapt the hierarchy to the articulatory skills of their P and the hierarchy can be modified during the treatment to reflect Ps’ skills.

— Modeling by the C appears to be an effective strategy.

— When targeting and modeling yawning, throat clearing, sighing, C should mimic P’s natural breathing patterns.

— The sighing of vowels is most successful when it begins with C modeling production on a slow and long exhalation.

— To assist Ps in the initiation and/or the sustaining of sounds, the investigators recommend using visual cues (e.g., hand movement) or sustaining tremolos using a guitar.

— Repetition paired with “attention and motivation” (p 561) increased the accuracy of imitation.

— The investigators note that adding a melody to the vocalizations when using this technique has equivocal effects. That is, it facilitated progress in some Ps and impeded progress with other Ps.

 

 

DYNAMICALLY CUED SINGING

 

 

  • Description: In the singing of songs, C pauses to cue P to produce the targeted word/words.

 

  • Evidence: (see also Item #9 above)

– Rhythm appeared to profit more from this technique than intonation.

– This technique seemed effective in encouraging attention as indicated by

  • increased eye contact of more than 50% in all Ps
  • limited increased rate in 6 of the 7 Ps.

– Cueing can be helpful to those who are struggling with this technique. EXAMPLE:

  • A P who perseverated a nonsense syllable was able to produce the target word when the C provided facial cues (mouthing or facial expressions.)

 

  • Hints:

– Cs should monitor the frequency of use of this technique as too frequent use could be associated with distraction or loss of interest.

– It is best to use familiar songs with this technique. Improvised songs are not as successful.

– Also Cs should avoid using phrases that tap the Ps’ internal states as they appear to be a distraction.

 

 

MUSICALLY ASSISTED SPEECH

 

 

  • Description: C identifies common phrases that are used in activities of daily living and in conversation and pairs them with familiar melodies. The phrases are taught in isolation and in role-playing of daily activities.

 

  • Evidence: (see also Item #9 above)

– Gains associated with articulation and fluency were observed with this technique.

  • Ps with articulation problems improved 10% to 30% in intelligibility
  • Ps with fluency problems rate of speech improved up to 15%.

– Ps performed better when a familiar song was reviewed first and then the daily living/conversational phrase was inserted into the melody of the familiar song. EXAMPLE:

  • Ps’ articulatory accuracy and prosody were better when Cs first introduced the targeted familiar song with its original/familiar lyrics and then used the same melody inserting the targeted daily activity/conversational phrase compared to initially targeting the daily/activity/conversational phrases paired with the familiar melody.
  • When Cs’ initially targeted the daily/activity/conversational phrases paired with the familiar melody, Ps seemed confused 80% of the time.
  • Six of the 7 Ps performances improved when Cs enhanced the rhythm of the songs by rhythmically cuing beats and accents using rhythmic cues such as drum beating or finger tapping.
  • Ps with dysarthria generally responded better to staccato (word by word or even syllable by syllable) and slow beats.
  • Ps with fluency (i.e., number or words in a phrase) problems in the absence of articulation problems generally responded better to focusing on short phrases instead of single words/syllables.
  • Ps have individual differences regarding how much setting up of the context is appropriate during the role-playing portion of this technique.

 

  • Hints:

– First present the familiar song with its standard lyrics and then insert the targeted phrases into the familiar melody.

— As a preparatory cue, Cs should use rhythmic cues (e.g., guitar strumming, finger tapping) at the beginning of each target phrase.

– Consistently pair a targeted phrase with the same familiar song.

– If a P is having trouble with a targeted phrase, consider changing the familiar song that has been paired with that phrase.

– Cs should remember to adjust the tempo of the familiar melody to optimize Ps’ production. Usually the adjustment is slowing the tempo but the tempo can be too slow or staccato for some Ps or contexts.

– Although Cs should provide some imaginary context for the role-playing portion of this task, too much attention to setting up the context is distracting.

 

 

RHYTHMIC SPEECH CUING

 

 

  • Description: P motorically claps or taps a drum to the rhythm of a target phrase. The targets can be song lyrics, daily activity phrases, or conversational phrases.

 

  • Evidence: (see also Item #9 above)

– Five of the Ps spontaneously added melody to the targeted phrases.

– Targets that had been used in the Musically Assisted Speech technique were increasingly successful.

– Ps had trouble separating rhythm and melody for the speech targets. That is some Ps sang rather than spoke speech targets using the targeted rhythm.

– A P with hemiplegia, apraxia, and rhythm problems responded well to (1) rhythm targets when the task was adapted to her physical limitations and (2) the targets initially targeted 2 syllable words and gradually moved to 3 word phrases.

– Ps with rhythm problems but not apraxia or with mild apraxia responded best to whole phrase targets.

– The investigators reported that for 6 of the 7 Ps, improved rhythm in speech and singing was “correlated with assertiveness of vocal quality” (p. 565.)

 

  • Hints:

– Cues include:

  • Beats that are “slow and steady” (p. 558) and adapted to the P’s skill level.
  • For song lyrics, the rhythm of the song is a good cue
  • For speech phrases, the rhythm of natural prosodic speaking patterns is the preferred cue.

– Using song melodies tend to be more effective than speech.

– When targeting speech, Cs should monitor Ps’ addition of melody to the target.

– Inclusion of multimodality cues and temporal cues can help P in imitating the C.

 

 

ORAL MOTOR EXERCISE

 

 

  • Description: The purpose of this technique is to improve “oral motor formations” (p. 558.) This is accomplished by C directing P to observe him/her carefully and then modeling a small part of a familiar song using exaggerated mouth and tongue movements.

 

  • Evidence: (see also Item #9 above)

– The investigators noted that this technique was associated with considerable progress in articulatory accuracy and vocal quality. One P did not respond well to this technique but that P was drowsy and inattentive during sessions.

 

  • Hints:

– C should correct P’s errors and repeat the same target multiple times.

– C’s feedback should be sensitive to P’s skill level, attention skills, motivation, and progress.

– Cs should be careful to give clear instructions and feedback and to monitor P’s performance carefully.

– This technique often is not successful with Ps with eye contact and/or attention problems. Dynamically Cued Singing or Vocal Intonation are recommended in such cases.

– Cs should be sure to allow sufficient time for Ps to process what has been modeled and to perform the target. It is best to establish a clear rhythm of modeling-waiting-responding.

 

 

VOCAL INTONATION

 

 

  • Description: C model exaggerated intonation patterns for speech phrases associated with different meanings. Cs provide visual cues (e.g., hand or head motions) representing changes in intonation/pitch as needed to achieve a positive outcome.

 

  • Evidence: (see also Item #9 above)

– The investigators noted that Ps progressed in the ability to modulate their pitch, intonation, and loudness.

– Progress was reported to have generalized out of the clinic into the nursing home context for 2Ps.

– As the result of this technique, Ps appeared more spontaneous and natural.

– Tempos that were too slow or excessively exaggerated interfered with progress.

 

  • Hints:

– The use of visual cues (e.g., hand movements representing changes in intonation) facilitated progress.

– The use of role-playing helped Ps generate intonation patterns that were appropriate to the context.

– The ideal tempo appears to be slow and clear but within normal limits for tempo and intonation.

 


Medina (1990)

December 27, 2017

EBP THERAPY ANALYSIS

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

Key:

A = Administrator

C = Clinician

EBP = evidence-based practice

Gain1 = Gain score from Pretest to Post test 1

Gain2 = Gain score from Post test 1 to Post test 2

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

SOURCE: Medina, S. L. (1990). The effects of music on second language acquisition. Paper presented at the Annual Meeting of the Teachers of English to Speakers of Other Languages (San Francisco, CA, March 1990) ERIC Educational Resources Information Center data base. ERIC Document # ED 352-834 retrieved from http://www.geocities.ws/ESLmusic/articles/print/article02.html  on March 8, 2015.

 

REVIEWER(S): pmh

 

DATE: December 26, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY:  C+ (The highest possible grade based on the design of the study, Prospective, Nonrandomized Group with Controls, is B+.) The assigned overall grade represents the quality of the evidence supporting the intervention; it is not meant as a judgment regarding the quality of the intervention.

 

TAKE AWAY: Second-graders who were speakers of Spanish and learning English as a second language were treated with one of four story-based interventions that compared music versus speech as a presentation strategy and illustrations versus no illustrations as extralinguistic support. The target of the intervention was increased receptive vocabulary. Inferential statistics revealed that there were no significant differences between music versus speech and the illustration versus no illustration contexts. This was interpreted as supporting the use of music as an intervention because it yielded results similar to speech only presentations. Analysis of descriptive statistics suggested that while low proficiency students improved performance at follow-up, high proficiency students’ performance decreased.

 

  1. What type of evidence was identified?

 

  • What was the type of evidence? Prospective, Nonrandomized 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? Unclear

– Participants (Ps) were initially sorted into 4 groups based on performance on a vocabulary test.

– The investigator then randomly assigned members of the groups to one of four treatment groups. P. 4 this is my interpretation it may be wrong but the writing is not clear to me

 

  • If there were groups and Ps were not randomly assigned to groups, were members of groups carefully matched? Unclear

– matching/sorting is on the basis of pretreatment vocabulary. Then the Ps were randomly assigned—sounds more like block assignment to me.

If the answer to 2a and 2b is ‘no’ or ‘unclear,’ describe the assignment strategy:

 

 

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

 

 

  1. Were the groups adequately described? No.

 

–           How many Ps were involved in the study?

  • total # of Ps:   48
  • # of groups: 4
  • Names of groups and the number of participants in each group:

     ∞ No Music- Illustrations, N = 13

     ∞ No Music- No Illustration, N = 11

     ∞ Music- Illustrations, N = 12

     ∞ Music – No Illustrations, N = 12

 

CONTROLLED CHARACTERISTICS:

  • language skills: Spanish speaking, limited English proficiency
  • educational level of parents: Second Grade

 

DESCRIBED CHARACTERISTICS:

  • location: Suburb of Los Angeles (CA)
  • Social-Economic Status: Students in the school were primarily low income

 

–   Were the groups similar before intervention began? Unclear

 

– Were the communication problems adequately described? No

  • Participants (Ps) were Spanish speakers who were learning English as a Second Language.

 

 

  1. Was membership in groups maintained throughout the study?
  • Did each of the groups maintain at least 80% of their original members? Yes, probably. Originally, there were 52 Ps but 4 Ps dropped out. The distribution of those who discontinued was not identified but the overall maintenance level was 92%

 

  • Were data from outliers removed from the study?

 

 

  1. Were the groups controlled acceptably? Unclear
  • 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 target groups constant? Yes

 

 

  1. Was the outcome measure appropriate and meaningful? Yes
  • OUTCOME #1: The amount of gain in receptive vocabulary
  • The outcome measure was subjective.
  • The outcome measures was NOT objective.

 

 

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

 

 

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

Summary Of Important Results

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

 

 

PRE AND POST TREATMENT ANALYSES

 

  • OUTCOME #1: The amount of gain in receptive vocabulary

∞ There were no significant differences for music versus no music and illustration versus no illustration (and their interactions) among the 4 treatment groups at the post test 1 (immediately after the intervention) and post test 2 (follow up, 1.5 weeks after intervention.)

     ∞ The investigator noted some patterns descriptively:

  • Immediately after treatment (post test 1) and the 1.5 week delay (post test 2 or follow up) the scores of Ps receive music treatment and viewing illustrations tended to be higher.

    ∞ The following patterns also were evident in the description of the results

  • Average gains at post test 1 following the 4 treatment sessions ranged from 0.73 (No Music, No Illustration Group) to 1.5 (Music and Illustration Group.)
  • Average gains at post test 2 (or follow up) ranged from 0.82 (No Music, No Illustration Group) to 1.75 (Music and Illustration Group.)

     ∞ The investigator also described the performance of a small group of Low Proficiency Ps (i.e., Ps who had scores below 8 of 20 items correct on the pretest.)

  • Low Proficiency Ps tended to gain more than higher proficiency Ps.
  • Average gains at post test 1 ranged from 0.33 (No Music, No Illustration Group) to 2.33 (Music and Illustration Group.)
  • Average gains at post test 2 (follow up) ranged from 1.00 (No Music, No Illustration Group) to 3.33 (Music and Illustration Group.)

 

  • What was the statistical test used to determine significance? ANOVA
  • Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance?  NA, no EBP data were reported.

 

 

  1. Were maintenance data reported? Yes. The difference in gains from post test 1 to post test 2 were not compared using inferential statistics. However, post test 2 performance regularly outpaced post test 1 performance. This suggests that Ps, not only maintained their gains but that the gains increased over the 1.5 weeks.

 

 

  1. Were generalization data reported? No

 

 

  1. Describe briefly the experimental design of the investigation.
  • Four groups of 2nd grade speakers of Spanish who were also English Language Learners received a story-related treatment to improve receptive vocabulary.

 

  • There were four different versions of the story-related treatment. The Ps listened to a cassette recorded story that included the target. The 4 versions were

∞ No Music- Illustrations, story spoken accompanied by illustrations

∞ No Music- No Illustration, story spoken accompanied but no illustrations

∞ Music- Illustrations, story sung accompanied by illustrations

∞ Music – No Illustrations, story sung accompanied by no illustrations

 

  • The spoken and sung versions of the story had identical scripts.

 

  • Prior to the initiation of treatment, the investigator met with the Ps to establish rapport and then she administered a pretest (baseline.)

 

  • Treatment lasted for 4 days and then the investigator administered Post Test 1.

 

  • One and one-half weeks following the termination of the intervention, Post Test 2 (i.e., follow-up) was administered.

 

  • Receptive vocabulary scores were compared using two 2-way (2×2, Medium x Extralinguistic Support) ANOVA for the following dependent measures:

–   Gain score from Pretest to Post test 1 (Gain1)

–   Gain score from Post test 1 to Post test 2 (Gain2)

 

  • The condition each had 2 aspects:

– Medium: Music; No Music

– Extralinguistic Support: Illustrations: NO Illustrations

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C+

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate whether (1) stories set to music were associated with the same amount of improvement in receptive vocabulary as stories presented orally and (2) stories paired with illustrations were associated with the same amount of improvement in receptive vocabulary as stories presented without illustrations.

 

POPULATION: Second language learners

 

MODALITY TARGETED: Receptive vocabulary

 

ELEMENTS OF PROSODY USED AS INTERVENTION:   music (pitch, rhythm)

 

DOSAGE: small groups; 4 days; tapes (spoken or song) were played 3 times in each treatment session

 

STIMULI: songs, spoken scripts, and illustrations

 

MAJOR COMPONENTS:

 

  • The administrator (A) provided one of four treatments to each of the groups of Ps:

∞ No Music- Illustrations, N = 13

∞ No Music- No Illustration, N = 11

∞ Music- Illustrations, N = 12

∞ Music – No Illustrations, N = 12

 

  • Overall, the treatment sessions were similar. The Ps were treated in groups sessions in which A played a prerecorded sung or spoken story 3 times. The story was accompanied by pictures for the “Illustration” treatment groups but not for the “No Illustration” treatment group. The stories for all groups were the same and used identical scripts.

 

  • For the Music and No Music Treatment conditions, the tapes were clear and intelligible. Both Music and No Music tapes were described as “appealing.” The song for the Music tape was a simple tune.

 

• For the Illustration and No Illustration conditions, the A displayed large pictures depicting the story. Written words were not included in the Illustration condition and, of course, the A did not use the pictures for the No Illustrat


Martikainen & Korpilahti (2011)

November 15, 2017

EBP THERAPY ANALYSIS for

Single Case Designs

NOTES:

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

Key:

C = Clinician

CAS = childhood apraxia of speech

EBP = evidence-based practice

MIT = Melodic Intonation Therapy

NA = not applicable

P = Patient or Participant

PCC = Percentage of Consonants Correct

PMLU = Phonological Mean Length of Utterance

PVC = Percentage of Vowels Correct

PWC = Proportion of Whole-Word Correctness

PWP = Proportion of Whole-Word Proximity

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

WNL = within normal limits

 

SOURCE: Martikainen, A-L, & Korpilahti, P. (2011). Intervention for childhood apraxia of speech: A single-case study. Child Language Teaching and Therapy, 27 (1), 9- 20.

 

REVIEWER(S): pmh

 

DATE: November 14, 2017

 

ASSIGNED OVERALL GRADE: D+   (The highest possible grade, based on the design of the investigation, is D+. The Assigned Overall Grade merely represents the quality of the evidence supporting the intervention and should not be construed to be a comment of the quality of the intervention.

 

TAKE AWAY: The results of this single case study revealed that a combined intervention in which Melodic Intonation Therapy (MIT) followed by a course of the Touch-Cue Method (TCM) resulted in improved speech accuracy in a Finnish-speaking 4-year-old child diagnosed with Childhood Apraxia of Speech (CAS.)

                                                                                                           

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

  

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

                                                                                                           

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

  

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

– How many Ps were involved in the study? List here: 1

– CONTROLLED CHARACTERISTICS          

  • cognitive skills: nonverbal cognitive skills within normal limits (WNL)
  • receptive language: WNL
  • hearing: WNL
  • diagnosis: CAS (8 of 11 speech and nonspeech CAS characteristics)
  • dysarthria: no signs
  • speech related structures: WNL

– DESCRIBED CHARACTERISTICS

  • age: 4;7 at the beginning of the investigation
  • gender: female
  • birth and medical history: WNL

* first word: 12 months but for 6 months she did not use words

  • multiword utterances: 36 months
  • expressive language:

Poor Finnish word naming

     – Phonetic Inventory– all vowels and consonants (except /d, l, r/)

     – Speech Sound errors — inconsistent vowel substitutions and distortions including some nasalization; inconsistent consonant substitutions and omission

     – Limited speech

     – Unintelligible

  • receptive language: WNL
  • family history of speech-language problems: multiple family members
  • age of first referral: 3;5
  • previous speech-language therapy: began 3 months after referral; 12 sessions between 3;8 an 4;6

                                                 

– Were the communication problems adequately described? Yes

  • The disorder type:  CAS
  • Other aspects of communication that were described:

limited, unintelligible speech

     – consonant inventory limited at initial evaluation by beginning of investigation intervention (at 4; 7) only missing /d/, /l/, and /r./

     – at initial evaluation –inconsistent use of vowels, although all Finnish vowels were in the vowel inventory

     – at the beginning of the investigation intervention, the participant (P) errors included:

          ∞ inconsistent errors in spontaneous speech and in imitation of single words

           ∞ consonant omission

           ∞ vowel substitutions and omission as well as nasalizatinon

           ∞ articulatory groping noted in imitation of short sentences but not spontaneous speech and picture naming

          ∞ syllable shapes were simple

           ∞ polysyllabic words reduced

           ∞ inflections omitted

           ∞ could not produce trisyllables in imitated diadochokinetic task but monosyllable repetitions were WNL

           ∞ protruding lips and alternating lip protrusion and retraction task was mildly impaired

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Not applicable, there was only one P.
  • If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable (NA) 
  • Were any data removed from the study? No

 

  1. Did the design include appropriate controls? No, this was a case study.                                                                 
  • Were baseline/preintervention data collected on all behaviors? Yes\
  • Did probes/intervention data include untrained stimuli? Yes
  • Did probes/intervention data include trained stimuli? No
  • Was the data collection continuous? No
  • Were different treatments counterbalanced or randomized? NA

  

  1. Were the outcome measures appropriate and meaningful? Yes

– OUTCOMES

  • OUTCOME #1: Percentage of Vowels Correct (PVC) from naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #2: Percentage of Consonants Correct (PCC) from naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #3: Modified Phonological Mean Length of Utterance (PMLU) from naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #4: Proportion of Whole-Word Proximity (PWP) from the naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #5: Proportion of Whole-Word Correctness (PWC) from the naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #6: Qualitative analysis of production from the naming of pictures modified from the Finnish Articulation Test

All of the outcomes that were subjective.

None of the outcomes that were objective. 

Interobserver deliability data were collected for the transcription of the words named in from the Finnish Articulation Test: 89% agreement

 

  1. Results:

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

  • OUTCOME #1: Percentage of Vowels Correct (PVC) on the naming of pictures modified from the Finnish Articulation Test:   strong improvement

∞ baseline to end of MIT: improved significantly

∞ end of MIT to end of no treatment phase: improved significantly

∞ end of no treatment phase to end of TCM:

∞   end of TCM to end of follow up: improved significantly

∞ descriptive: week 0 and week 6 (baseline) PVC = 54.8%, 57.8%, respectively; end of the study (week 36)   PVC = 93%

 

  • OUTCOME #2: Percentage of Consonants Correct (PCC) on the naming of pictures modified from the Finnish Articulation Test: strong improvement

∞ baseline to end of MIT: decreased significantly

∞ end of MIT to end of no treatment phase: improved significantly

∞ end of no treatment phase to end of TCM: improved significantly

∞   end of TCM to end of follow up: no significant change

∞ descriptive: week 0 and week 6 (baseline) PCC = 24%, 31.2%, respectively; end of the study (week 36)  PCC = 73.1%

 

  • OUTCOME #3: Modified Phonological Mean Length of Utterance (PMLU) on the naming of pictures modified from the Finnish Articulation Test: moderate improvement

∞ baseline to end of MIT: no significant improvement

∞ end of MIT to end of no treatment phase:  improved significantly

∞ end of no treatment phase to end of TCM: improved significantly

∞   end of TCM to end of follow up: improved significantly

∞ descriptive: week 0 and week 6 (baseline) PMLU = 6.12, 6.38, respectively; end of the study (week 36)  PMLU = 8.80

 

  • OUTCOME #4: Proportion of Whole-Word Proximity (PWP) on the naming of pictures modified from the Finnish Articulation Test: limited improvement

∞ baseline to end of MIT: no significant improvement

∞ end of MIT to end of no treatment phase: no significant improvement

∞ end of no treatment phase to end of TCM: no significant improvement

∞   end of TCM to end of follow up: no significant improvement

∞ descriptive: week 0 and week 6 (baseline) PWP = 0.64, 0.68, respectively; end of the study (week 36)  PWP = 0.91

 

  • OUTCOME #5: Proportion of Whole-Word Correctness (PWC) on the naming of pictures modified from the Finnish Articulation Test: moderate improvement

∞ baseline to end of MIT: no significant improvement

∞ end of MIT to end of no treatment phase: no significant improvement

∞ end of no treatment phase to end of TCM: improved significantly

∞   end of TCM to end of follow up: no significant change

∞ descriptive: week 0 and week 6 (baseline) PWC = 0.17, 0.19, respectively; end of the study (week 36)  PWC = 0.39

 

  • OUTCOME #6: Qualitative analysis of production on the naming of pictures modified from the Finnish Articulation Test: authors reported that phoneme production and sequencing improved (Moderate improvement)

 

  1. Description of baseline:
  • Were baseline data provided? Yes, for Outcomes 1 through 5 there were two baseline session, six weeks apart.                                         
  • Was baseline low (or high, as appropriate) and stable? For Outcomes 1 through 5, all the baselines were low and stable.
  • Was the percentage of nonoverlapping data (PND) provided? No

 

  1. What is the clinical significanceNA

 

  1. Was information about treatment fidelity adequate? Not Provided

 

  1. Were maintenance data reported?  Yes
  • Improvements in Outcomes #1 though 5 were maintained or increased at follow up.

 

  1. Were generalization data reported? Yes, since untrained stimuli were used for all the Outcomes, the Results (item #8) can be viewed as generalization data.

  

  1. Brief description of the design:
  • This single case study explored the effectiveness of administering MIT and TCM sequentially to treat a 4-year old Finnish child who had been diagnosed with CAS.
  • The outcome measures were concerned with consonant and vowel accuracy as well as Whole-word Accuracy and were derived from the picture naming task of the Finnish Articulation Test.
  • The schedule of testing and treatment was

∞ 2 sessions of baseline at Week 0 and Week 6

∞ 6 weeks of MIT running from Week 6 to Week 12.

∞ 6 weeks of no treatment from week 12 to Week 18

∞ 6 weeks of TCM from Week 18 to Week 24

∞ Follow-up assessment (Week 36) after 12 weeks of no treatment (Week 24 to Week 36)

  • The measures were compared from

∞ baseline (Week 6) to end of MIT (Week 12),

∞ end of MIT (week 12) to end of no treatment phase (Week 18),

∞ end of no treatment phase (Week 12) to end of TCM (Week 24), and

∞ end of TCM (Week 24) to end of follow up (Week 36).

 

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

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of a combined treatment program using MIT and TCM

POPULATION: Childhood Apraxia of Speech; Children 

MODALITY TARGETED: production

ELEMENTS OF PROSODY USED AS INTERVENTION: intonation

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: speech sound accuracy; whole word accuracy

DOSAGE: 30 minute sessions, 3 times a week for 6 week (each treatment)

ADMINISTRATOR: SLP

MAJOR COMPONENTS:

  • There were 2 treatments: a modified version of MIT and TCM

 

MELODIC INTONATION THERAPY (MIT)

  • The stimuli for MIT were 3 sentence lists in the Finnish language. Each list

– contained 10 sentences that were 2 to 3 words long

– included topics that were developmentally appropriate

– consisted of bisyllable words which were in the P’s phonetic repertoire. (There was one exception to this final characteristic of the lists.)

  • At the beginning of treatment, the clinician © simultaneously signs Finninsh with the intoned speech. This support is gradually faded as P becomes familiar with the sentences.
  • C models a target sentence 2 times while intoning it.
  • C and the participant (P) intone the target sentence simultaneously.
  • C models the intoned version of the target sentence.
  • P intones the sentence independently. The C can facilitate P’s production if necessary.
  • C asks P a question to elicit the target sentence spontaneously.

 

TOUCH-CUE METHOD (TCM)

  • The practice materials were syllable sequences (nonsense syllables) and meaningful words. The practice materials were made up of any Finnish vowel and the some of following phonemes: /p, k, s, l/.
  • There were 2 phases .

PHASE 1

  • There were 3 steps. All the stimuli were nonsense syllables.
  • Criterion for advancement was 100% correct for 3 consecutive sessions.

PHASE 1—STEP 1

  • P practiced producing a single nonsense syllable /pa/ or a repeated nonsense syllable /papa/.

PHASE 1—STEP 2

  • P practiced producing a nonsense bisyllable with identical vowels but different consonants /paka/.

PHASE 1—STEP 1

  • P practiced producing a nonsense bisyllable with different vowels and different consonants /paku/.

PHASE 2

  • The target stimuli were now meaningful bisyllable words.
  • Criterion for advancement was 90% correct for 3 consecutive sessions.
  • C modeled the target word 2 or 3 times while simultaneously using touch cues to facilitate production.
  • C and P practiced the target word simultaneously 5 to 10 times continuing to use touch cues.
  • Auditory and visual cues were gradually faded until P produced the target word 5 times (while still being assisted with touch cues.)

 

 


Tomaino (2012)

October 24, 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

CT = Picture-Based Conversation Therapy

EBP = evidence-based practice

MT = music therapy

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE:  Tomaino, C. M. (2012). Effective music therapy techniques in the treatment of nonfluent aphasia. Annals of the New York Academy of Sciences, 1252, 312-317. doi: 10.1111/j.1749-6632.2012.06451.

 

REVIEWER(S): pmh

 

DATE: October 11, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY OF STUDY 1– PROTOCOL ANALYSIS: D+ (The highest possible grade for this investigation is C based on the design of the investigation– Narrative, Qualitative Research involving Multiple Participants). This summary of the original paper omitted several important points which likely account for the reduced grade. The original paper will be reviewed at a later date.

 

ASSIGNED GRADE FOR OVERALL QUALITY OF STUDY 2– GROUP COMPARISON: C + (The highest possible grade for this investigation is A based on the design of the investigation—Prospective, Randomized Group Investigation with Controls.) This summary of the original unpublished paper omitted several important points which likely account for the reduced grade.

 

TAKE AWAY: The author summarized two investigations to support the contention that music therapy can be used to treat nonfluent aphasia effectively. The author reported that there are at least 7 music therapy (MT) techniques that are useful and that music therapy and picture-based conversation therapy (CT) result in significant improvement in performance on selected portions of 2 tests frequently used to assess people with nonfluent aphasia.

 

NOTE: The author summarized two studies. Study 1 was a Protocol Analysis of Music Therapies and Study 2 was a comparison of Music Therapy (MT) and Conversation Therapy (CT). Each study will be analyzed and summarized separately.

 

STUDY 1: PROTOCAL ANALYSIS

 

NOTE: This investigation was only summarized in the paper under review. This may account for some unwarranted criticism. The original paper will be reviewed at a later date.

 

  • What type of evidence was identified?

                                                                                                           

– What was the type of evidence? Descriptive, Qualitative

                                                                                                          

– What was the level of support associated with the type of evidence?

Level = C

 

                                                                                                           

  • Group membership determination:

                                                                                                           

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

 

  • Was administration of intervention status concealed?

                                                                                                           

– from participants? Unclear

from clinicians? No

from analyzers? No

 

 

  • Were the groups adequately described? No

 

How many Ps were involved in the study?

total # of Ps: 7

     ∞ # of groups: 1

 

– CONTROLLED P CHARACTERISTICS

  • diagnosis: Nonfluent aphasia

 

– DESCRIBED P CHARACTERISTICS

  • gender: 2m; 5f
  • time post onset: 9 months to 20 years

 

– Were the groups similar before intervention began? NA, this was not a group comparison.

                                                         

– Were the communication problems adequately described? No

     ∞   disorder type: Nonfluent Aphasia

 

 

  • Was membership in group maintained throughout the study?

                                                                                                             

– Did at least 80% of their original participants (Ps) complete the specified amount of intervention? Yes

                                                               

– Were data from outliers removed from the study? No

 

 

  • Were the groups controlled acceptably? NA, this was not a group comparison.

 

 

  • Were the outcomes measure appropriate and meaningful? No, the summary provided in this paper did not describe the outcomes, although it appears they are described in the original article.

 

                                                                                                                       

  • Were reliability measures provided?

– Interobserver for analyzers? No

Intraobserver for analyzers?   No

– Treatment fidelity for clinicians? No

 

 

  • What were the results of the description of the results? This investigation involved the viewing of videotaped MT sessions by a panel of independent judges to identify effective treatment techniques using a descriptive analysis for each of the 7 Ps.. The author identified the following techniques as effective:

 

– Singing Familiar Songs

– Breathing into Single-Syllable Sounds

– Musically Assisted Speech

– Dynamically Cued Singing

– Rhythmic Speech Cuing

– Oral Motor Exercises

– Vocal Intonation

 

 

 

 

  • What is the clinical significanceEBP measures were not provided.

 

 

  • Were maintenance data reported? No

 

 

  • Were generalization data reported? No

 

 

  • A brief description of the experimental design of the investigation:

 

– Four independent judges descriptively analyzed 66 videos of 7 Ps with nonfluent aphasia receiving MT.

 

— The results of the analyses revealed 7 effective MT techniques.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: D+

 

 

STUDY 2: TREATMENT GROUP COMPARISON

 

 

  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

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No
  • from clinicians? No
  • from analyzers? unclear __x__

                                                                    

 

  1. Were the groups adequately described? No

 

– How many Ps were involved in the study?

 

  • total # of Ps:   40
  • # of groups:   2
  • List names of groups and the # of participants in each group:

         – Music Therapy (MT): 20 Ps

– Picture-Based Conversation Therapy (CT): 20 Ps    

 

– DESCRIBED P CHARACTERISTICS

  • expressive language: Mean initial expressive language score for Ps completing treatment I

         – MT initial score 60.6

         – CT initial score 46.8

 

  • receptive language: All Ps were considered to have good comprehension skills

 

  • previous therapy: “All Ps had receive one course of speech therapy…no longer receiving speech therapy” (p. 315)

 

  • Were the groups similar before intervention began? No

                                                         

  • Were the communication problems adequately described?

 

  • disorder type: Nonfluent Aphasia
  • functional level: unknown

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

  • Did each of the groups maintain at least 80% of their original members? No

 

– MT group: 90% of the Ps completed the intervention

– CT group: 40% of the Ps completed the intervention t

                                                               

  • Were data from outliers removed from the study? No

 

 

  1. Were the groups controlled acceptably? No

                                                                                                             

  • 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 foil/comparison and the target groups constant? Yes

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

OUTCOMES

 

  • OUTCOME #1: Performance on the Western Aphasia Battery (following directions, repetition, sentence completion)

 

 

  • OUTCOME #2: Performance on the Test of Adult and Adolescent Word Finding (naming nouns)

 

  • BOTH the outcome measures were subjective:

 

  • The outcome measures were NOT 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 description of the results?

 

– Summary Of Important Results

 

NOTE: The two treatment groups were not compared — only the differences between the pre and post intervention scores within each treatment group were provided.

 

OUTCOME #1 and OUTCOME #2: Both treatment groups expressive language improved significantly from preintervention testing to post intervention testing I

– MT group:

∞   preintervention score = 60.6

∞ postintervention score = 67.2

 

– CT group:

∞   preintervention score = 46.8

∞ postintervention score = 53.6

 

– What was the statistical test used to determine significance? t-test:  

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significanceEBP data were not provided.

 

 

  1. Were maintenance data reported? No

 

 

  1. Were generalization data reported? No

 

 

  1. Brief Description of the experimental design of the investigation:

 

  • Forty Ps diagnosed with nonfluent aphasia were randomly assigned to either the MT or the CT treatment groups.

 

  • Ps were tested 3 times:

– before intervention (preintervention)

– during intervention (half way through the 12 weeks of intervention)

– at the end of the intervention (postintervention)

 

  • This summary of the research only reported the comparison of the pre- and post-intervention scores for each group. That is, Ps in the 2 groups were only compared pre and post intervention. The Ps in the 2 groups were not compared to one another.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C+

 

 

PROTOCOL ANALYSIS

 

SUMMARY OF INTERVENTION

 

PURPOSE: To describe effective MT based treatment techniques for nonfluent aphasia

 

POPULATION: Nonfluent Aphasia; Adults

 

MODALITY TARGETED: production

 

ELEMENTS OF PROSODY USED AS INTERVENTION: music (pitch/intonation/inflection, rhythm, tempo, loudness, pause, rhythm), rhythm,

 

MAJOR COMPONENTS:

 

  • The judges identified 7 effective MT techniques:

– Singing Familiar Songs

– Breathing into Single-Syllable Sounds

– Musically Assisted Speech

– Dynamically Cued Singing

– Rhythmic Speech Cuing

– Oral Motor Exercises

– Vocal Intonation

 

  • Each of the 7 techniques is described below:

 

 

TECHNIQUE— Singing Familiar Songs:

 

  • P sings a familiar song with the clinician (C.)

 

  • C prompts P to sing the lyrics that appear to be easiest for him/her to produce repeatedly.

 

  • C can adjust the tempo and loudness of the song to assist P with production and interaction.

 

PROS OF Singing Familiar Songs:

 

  • The rhythm of singing tended to be stable and good even when Ps had difficulty with the rhythm of speaking.

 

  • The synchronization of music and behaviors such as tapping (temporal entrainment) and fluency of singing was reported to be positively correlated.

 

CONS OF – Singing Familiar Songs:

 

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

 

 

TECHNIQUE– Breathing into Single-Syllable Sounds:

  • C used the following strategies to elicit speech sounds:

– mirror P’s breathing pattern rather than impose a breathing pattern

– targets naturally occurring nonspeech sounds: breathing, yawning, sighing, clearing voice (?)

– cues initiating, sustaining, and synchronizing speech sounds and breathing using hand movements (i.e., a visual cue)

 

  • C directs P to breathe “into single-syllable sounds” by producing the sound during a slow and long exhalation.

 

  • C moved from vowel to consonant targets. The consonants appeared to be targeted in a hierarchy: bilabials, alveolar stops, and velar stops.

 

 

PROS OF Breathing into Single-Syllable Sounds:

 

  • P’s focus on breathing facilitated relaxation

 

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

 

 

TECHNIQUE– Musically Assisted Speech:

 

  • C selects common phrases (e.g., How are you today?) paired with a familiar tune (e.g., Swing Low, Swing Chariot)

 

  • C presents the selected familiar song with its original lyrics and then presents it with the targeted common phrase.

 

PROS OF Musically Assisted Speech:

 

  • As Ps become more familiar with a tune, motivation and success tend to increase.

 

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

 

 

TECHNIQUE– Dynamically Cued Singing:

 

  • Using a familiar song, C cues P’s participation in the singing of the song by

– pausing at the end of well-know phrase, anticipating P’s production of the next phrase

– when P finishes his/her part, C then produces another phrase and pauses again for P to join in

 

PROS OF Dynamically Cued Singing:

 

  • the turn taking increases P motivation and mimics a conversation

 

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

 

 

TECHNIQUE– Rhythmic Speech Cuing (Speech-Motor Entrainment):

 

  • C guides P to clap or tap to the rhythm of a phrase. Either hand may be used to tap.

 

  • The phrase is spoken but may be a

– lyric from a song

– a common phrase from activities of daily living

– a phrase relevant to the context

 

  • C facilitates P’s productions by

– modifying the tempo to optimize P’s performance

– using slow steady beats

 

PROS OF Rhythmic Speech Cuing:

 

– If a P was successful using motor cueing, he/she was also successful singing the rhythm of a song.

 

 

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

 

TECHNIQUE– Oral Motor Exercises:

 

  • C models short phrases from a familiar song using exaggerated mouth and tongue movements.
  • C directs P to observe and then imitate C’s production

 

PROS OF Oral Motor Exercises:

  • C should be careful to allow sufficient time for P to respond to this task.

 

 

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

 

TECHNIQUE– Vocal Intonation:

 

  • C repeatedly targets the production of intoned phrases modifying inflection, pitch, and loudness so that the phrases mimic conversational speech.

 

  • Initially, intonation may be exaggerated.

 

  • C uses visual cues (e.g., hand cues) to facilitate production of intonation changes.

 

PROS OF Vocal Intonation:

 

  • Visual cues facilitated natural production of prosody.

 

 

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

 

 

STUDY 2: TREATMENT GROUP COMPARISON

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of familiar songs and rhythmic motor-cued speech in treating nonfluent aphasia

 

POPULATION:  Nonfluent aphasia; Adults

 

MODALITY TARGETED: Production

 

ELEMENTS OF PROSODY USED AS INTERVENTION: music (pitch/intonation/inflection, rhythm, tempo, loudness, pause )

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: performance on the Western Aphasia Battery and the Test of Adult and Adolescent Word Finding

 

DOSAGE:  30 minute sessions, 3 times a week, for 12 week

 

ADMINISTRATOR: Music Therapist

 

MAJOR COMPONENTS:

 

NOTE: The administrator of the interventions will be referred to as the clinician (C.)

 

  • There were 2 interventions described in this investigation:

– Music Therapy (CT)

_ Picture-based Conversation Therapy

 

 

MUSIC THERAPY

 

 

  • C and P sang familiar songs.

– Using a familiar song, C cued P’s participation in the singing of the song by

∞ pausing at the end of well-know phrase, anticipating P’s production of the next phrase

∞ when P finished his/her part, C produced another phrase and paused again for P to join in

∞ C facilitated P’s accurate production by introducing finger-tapping.

 

  • C employed speech-motor entrainment

– • C guided P to clap or tap to the rhythm of a phrase. Either hand could be used to tap.

 

  • The phrase was spoken but it could be a

– lyric from a song

– a common phrase from activities of daily living

– a phrase relevant to the context

 

  • C facilitated P’s productions by

– modifying the tempo to optimize P’s performance

– using slow steady beats

 

 

PICTURE-BASED CONVERSATION THERAPY

 

  • C presented “picture-based conversational exercised” (p. 316.)

 

  • C facilitated P’s responses by

– providing visual cues

– using “participant’s verbal responses to these cues” (p. 316.)


Ballard et al. (2015)

June 30, 2017

 

SECONDARY REVIEW CRITIQUE

 

 

KEY:

 

C = clinician

NA = not applicable

P = patient or participant

PEDro-P scale = Physiotherapy Evidence Database (PEDro-P) scale

pmh = Patricia Hargrove, blog developer

SCED scale = Single Case Experimental Design scale

SLP = speech-language pathologist

SR = Systematic Review

 

 

Source: Ballard, K. J., Wambaugh, J.L., Duffy, J. R., Layfield, C., Maas, E., Mauszycki, S., S., & McNeil, M. R. (2015). Treatment for acquired apraxia of speech: A systematic review of intervention research between 2004 and 2012. American Journal of Speech-Language Pathology, 24, 316-337.

 

Reviewer(s): pmh

 

Date: June 29, 2017

 

Overall Assigned Grade: B (The highest possible grade associated with this design, Systematic Review with Broad Criteria, is B. The grade reflects the overall quality of evidence associated with the interventions described in the research and does not represent a judgment about the interventions themselves.)

 

Level of Evidence:  B

 

Take Away: This Systematic Review (SR) included a broad range of research designs investigating the effectiveness of intervention for acquired apraxia of speech (AOS.) Most of the sources involved nonprosodic outcomes and/or treatment procedures with only 8 sources focusing on prosodic outcomes and/or prosodic treatment procedures. Accordingly, only those 8 sources are summarized and analyzed in this review. The findings indicated that treating prosody directly and using prosody to treat articulatory and/or naming outcomes can result in improvements.

 

What type of secondary review? Narrative Systematic Review

 

 

  1. 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:

  • internet based databases
  • references from identified literature
  • theses/dissertations
  • Google Scholar,

 

– Did the sources involve only English language publications? Yes

 

– Did the sources include unpublished studies? No

 

– 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

 

– 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? Yes

  • Interrater reliability for the classification of the level of evidence based on the experimental design of the investigation = 100%
  • Combined Interrater reliability for the Single Case Experimental Design scale (SCED) scale or the Physiotherapy Evidence Database (PEDro-P) scale = 96%
  • Interrater reliability regarding the level of confidence of diagnosis of apraxia of speech (AOS) = 93%

 

– Were assessments of sources sufficiently reliable? Yes

 

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

 

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

 

– Were there a sufficient number of sources? Variable, ultimately, the investigators reviewed 26 sources which is acceptable. However, only 8 of these were prosody related?.

 

  1. Description of outcome measures:

 

  • Outcome #1: Improved speech skills (Aitken Dumham, 2010; using music therapy)

 

  • Outcome #2: Improved naming skills (Aitken Dumham, 2010; using music therapy)

 

  • Outcome #3: Improved performance on standardized tests (Aitken Dumham, 2010; using music therapy)

 

  • Outcome #4: Improvement in duration (Cowell, 2010; Brendel, 2008; Mauszycki, 2008)

 

  • Outcome #5: Improved production of words or sounds within words (Wambaugh, 2012; including rate/rhythm control procedures)

 

  • Outcome #6: Improved articulatory accuracy/speech sound production (Brendel, 2008 using metrical pacing therapy; Mauszycki, 2008 hand tapping in unison with metronome)

 

  • Outcome #7: Reduced dysfluencies (Brendel, 2008 using metrical pacing therapy)

 

  • Outcome #8: Improved word production (van der Merwe, 2011, one component of the intervention involved rate increases; Schneider, 2005, one component of the intervention involved syllable by syllable production; Marangolo, 2011, parts of the intervention involved syllable segmentation or vowel prolongation)

 

 

  1. Description of results:

 

  • What measures were used to represent the magnitude of the treatment/effect size? No measures of the magnitude of the treatment effect/effect size were reported.

 

  • Summary overall findings:

 

– Overall, treatments using prosody as an intervention or treating selected aspects of prosody (duration and dysfluencies) tend to result in improvement in the speech of people with acquired AOS.

– The changes associated with the outcomes of interest in the review are

 

  • Outcome #1: Improved speech skills (Aitken Dumham, 2010; using music therapy)—greater improvement was noted with combined speech-language and music therapy than with either treatment alone

 

  • Outcome #2: Improved naming skills (Aitken Dumham, 2010; using music therapy) — greater improvement was noted with combined speech-language and music therapy than with either treatment alone

 

  • Outcome #3: Improved performance on standardized tests (Aitken Dumham, 2010; using music therapy) — greater improvement was noted with combined speech-language and music therapy than with either treatment alone

 

  • Outcome #4: Improvement in duration (Cowell, 2010; Brendel, 2008; Mauszycki, 2008)—improvement following self-administered computer speec programs was noted for word duration; sentence duration improved in a metrical pacing intervention but it did not improve with an articulation treatment

 

  • Outcome #5: Improved production of words or sounds within words (Wambaugh, 2012; including rate/rhythm control procedures) – Repeated Practice with Rate/Rhythm Control did NOT result in better results than Repeated Practice alone.

 

  • Outcome #6: Improved articulatory accuracy/speech sound production (Brendel, 2008 using metrical pacing therapy; Mauszycki, 2008 hand tapping in unison with metronome)– metrical pacing intervention resulted in improved articulation despite the fact that there was no feedback regarding articulation in the treatment protocol; hand tapping and the production of one syllable at time in the absence of attention to articulatory accuracy resulted in improved articulatory accuracy

 

  • Outcome #7: Reduced dysfluencies (Brendel, 2008 using metrical pacing therapy)— improved fluency follow a metrical pacing intervention not with an articulation treatment

 

  • Outcome #8: Improved word production (van der Merwe, 2011, one component of the intervention involved rate increases; Schneider, 2005, one component of the intervention involved syllable by syllable production; Marangolo, 2011, parts of the intervention involved syllable segmentation or vowel prolongation) — word production improved in van der Merwe (2011) and Schneider (2005) intervention ; it was not clear what components of the interventions were effective. Moreover, the Manangolo (2011) treatment that incorporated modifications of prosody was out performed by Anodic tDCS stimulation.

 

  • Were the results precise? NA

 

  • 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? NA

 

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

 

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

 

  • Were the results in the same direction? Yes

 

  • Did a forest plot indicate homogeneity? NA

 

  • Was heterogeneity of results explored? No

 

  • Were the findings reasonable in view of the current literature? Yes
  • Were negative outcomes noted? Yes

           

                                                                                                                   

  1. Were maintenance data reported? Yes, some of the investigations that involved prosody explored maintenance.

 

 

  1. Were generalization data reported? Yes, some of the investigations that involved prosody explored generalization.

 

 

 

SUMMARY OF INTERVENTION

 

#1: Aitken Dunham (2010)

 

 

Population: Acquired AOS

 

Nonprosodic Targets: speech skills, naming skills, performance on standardized tests

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: music (melody), rate, loudness, pausing, rhythm (clapping to music)

 

Description of Procedure/Source #1— Aitken Dunham (2010)

  • There were 3 interventions:

– traditional speech and language intervention (8 step program, focusing on naming)

– music therapy (MT; singing, slow and gentle production of syllables, using songs producing phrases, modifying loudness and pauses during songs, clapping to songs.

– combined traditional and MT

 

Evidence Supporting Procedure/Source #1— Aitken Dunham (2010)

     – both interventions individually resulted in improvement in outcomes but a combined approach (traditional plus MT) was superior to either of the sole interventions

 

 

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#2: Cowell (2010)

 

Population: Acquired AOS

 

Prosodic Targets: word duration

 

Nonprosodic Targets: word accuracy

 

Description of Procedure/Source #2 —(Cowell, 2010; self administered computer program)

 

  • The P self-administered the invention using a computer program. The program included

– multimodality (auditory, visual, orthographic, visual object, somatosensory, sensory) stimulation

–   imagined production

– actual word production

 

Evidence Supporting Procedure/Source #2—(provide title)

 

  • Improvements for the intervention described above were superior to a foil treatment.

 

 

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#3: Marangolo (2011)

 

Population: acquired AOS

 

Nonprosodic Targets: word production

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: segregation of syllables (concordance), vowel prolongation

 

Description of Procedure/Source #3—(Marangolo, 2011)

 

  • Only the Behavioral Treatment that incorporated prosody is summarized here.

 

  • The Behavioral Treatment included

– Imitation of nonwords and words using a cuing hierarchy

– Modeling of nonwords and words with segregated syllable, prolonged vowels, and exaggerated articulation.

 

Evidence Contraindicating Procedure/Source #3—(Marangolo, 2011)

 

  • Manangolo (2011) treatment that incorporated modifications of prosody was out performed by Anodic tDCS stimulation.

 

 

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#4: Schneider (2005)

 

Population: acquired AOS

 

Nonprosodic Targets: (non)word production

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: syllable-by-syllable production (concordance_

 

Description of Procedure/Source #4—(Schneider, 2005)

 

  • 8 step continuum that included

– imitation

– unison speech

– syllable-by –syllable production

– tactile instructions

– verbal instructions

 

 

Evidence Supporting Procedure/Source #4—(Schneider, 2005)

 

  • P’s production of target nonwords improved.

 

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van der Merwe (2011)

 

Population: acquired AOS

 

Nonprosodic Targets: words (and nonwords)

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: rate

 

Description of Procedure/Source #5—(van der Merwe, 2011)

 

  • The Speech Motor Learning Program included

– a progression from imitated blocked practice producing nonwords to the production of real words

– the hierarchy was from less to more complex

– the practice schedule changed to random and variable practice

– self-monitoring tasks

– increases in targeted rates

– modifications in feedback

 

Evidence Supporting Procedure/Source #5— (van der Merwe , 2011)

 

  • The overall program resulted in improvement in word and nonword production.

 

Evidence Contraindicating Procedure/Source #5—(van der Merwe, 2011)

 

  • There were also changes in untreated behaviors which clouded the findings

 

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#6: Wambaugh (2012)

 

Population: acquired AOS

 

Nonprosodic Targets: words or sounds within words

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: rate, rhythm

 

Description of Procedure/Source #6—(Wambaugh, 2012)

 

  • P repeated the target 5 times after the C provided a model. Rate and rhythm were controlled. I have no idea what control of rate and rhythm means!

 

  • C provided feedback.

 

Evidence Supporting Procedure/Source #6—(Wambaugh (2012)

 

  • Rate/Rhythm procedures paired with Repeated Practice resulted in more improvements than Repeated Practice alone.

 

 

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#7: Brendel (2008)

 

Population: acquired AOS

 

Prosodic Targets: sentence duration, dysfluencies

 

Nonprosodic Targets: articulatory accuracy

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: rhythm, rate, loudness

 

Description of Procedure/Source #7—(Brendel, 2008)

 

  • Metrical Pacing Treatment included

– production of sentences in unison with a sequence of tones

– visual feedback comparing the amplitude of P’s production to the targeted tone sequence

– C provided feedback on rate, fluency, and matching of rhythm patterns

– C provided cues to facilitate accuracy (i.e., tapping, tactile cues, choral speech)

 

  • Metrical Pacing Treatment did not include attention to articulatory accuracy.

 

Evidence Supporting Procedure/Source #7—(Brendel, 2008)

 

  • Metrical Pacing Treatment resulted in improvements in prosodic and nonprosodic target while Articulation Treatment only resulted in improvements in nonprosodic targets.

 

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#8: Mauszycki (2008)

 

Population: acquired AOS

 

Prosodic Targets: duration

 

Nonprosodic Targets: sound production

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: rhythm, rate, syllable-by-syllable production (concordance)

 

Description of Procedure/Source #8—(Mauszycki, 2008)

 

 

  • The treatment included

– hand tapping

– production of one syllable at a time in unison with a metrodome

– the rate was modified to the needs of the P

– C modeled production

– unision productions with the C

– repetitions

– C provided feedback regarding the accuracy of the rate and rhythm.

 

  • The treatment did not involve attention of the accuracy of sounds.

 

 

Evidence Supporting Procedure/Source #8—(Mauszycki, 2008)

 

  • Improved utterance duration and sound production.

 

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