de Swart et al. (2003)

February 2, 2021

EBP THERAPY ANALYSIS

Treatment Groups

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

Key:

 C =  Clinician

 EBP =  evidence-based practice

 LSVT = Lee Silverman Voice Treatment 

 NA = not applicable 

 P =  Patient or Participant

 PLVT = Pitch Limiting Voice Treatment

 PD =  Parkinson’s disease

 pmh =  Patricia  Hargrove, blog developer

 SLP =  speech–language pathologist

SOURCE: de Swart, B. J. M., Willemse, S. C., Massen, B. A. M., & Horstink, M. W. I. M. (2003). Improvement of voicing in patients with Parkinson’s disease by speech therapy. Neurology, 60, 498-500.

REVIEWER(S): pmh

DATE: January 29, 2021

ASSIGNED GRADE FOR OVERALL QUALITY:  No grade assigned. This was not an intervention investigation, rather it could be considered ‘proof-of-concept’ research in which information from a single 30-minute procedure has application for the development of an intervention procedure.  

TAKE AWAY: This clinically related (not clinical intervention) research compares Pitch Limiting Voice Treatment (PLVT), Lee Silverman Voice Treatment (LSVT), and habitual speaking style to determine if PLVT can increase loudness like LSVT and also modulate pitch to avoid increased pitch level. This single session task served as a proof of concept for PLVT because the investigation indicated that both PLVT and LSVT resulted in increased loudness but only PLVT limited pitch increases.

1.  What type of evidence was identified? 

•  What was the type of evidence? Single Group Experimental Design with 3 tasks and 3 conditions (i.e., a repeated measure design) 

•  What was the level of support associated with the type of evidence? Level =  Not Applicable (NA); this was not an intervention investigation

2.  Group membership determination: 

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

3.  Was administration of intervention status concealed?

  from participants? No

•  from clinicians? No

•  from analyzers? Unclear  

4.  Was the group adequately described?  Yes 

– How many  Ps were involved in the study? 

•  total # of Ps: 32

•  # of groups: 1

– CONTROLLED CHARACTERISTICS

•  cognitive skills: Ps with dementia were excluded

•  expressive language: Ps who were diagnosed as having “severe, hardly intelligible dysarthria” (p.498) were excluded

•  diagnosis: Parkinson’s disease (PD)

•  social/emotional status: Ps with depression were excluded

•  neurological status: Ps with other comorbid neurological conditions were excluded 

•  hearing status: Ps with hearing loss were excluded

•  previous speech therapy: Ps with a history of speech therapy within a year of the investigation were excluded

•  Other: the Ps were from an outpatient service and they were consecutively identified from the P enrollments; Ps with “on-off” phenomena (p. 498) were excluded

– DESCRIBED CHARACTERISTICS

•  age: 36 years to 75 years

•  gender: 17m; 15f

•  vocal status: diagnosed with mild to severe voice disorders 

•  medications: All Ps were taking PD medications at the time of the investigation 

•  time since diagnosis: 1 to 18 years

–  Were the groups similar before intervention began?  NA 

  Were the communication problems adequately described? Yes 

•  disorder type:  (List) dysarthria associated with PD

•  functional level: mild to severe

5.  Was membership in groups maintained throughout the study?

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

•  Were data from outliers removed from the study?  No 

6.   Were the groups controlled acceptably?  NA

7.  Were the outcomes measure appropriate and meaningful? Yes

•  OUTCOME #1: Acoustic measure of loudness

•  OUTCOME #2: Acoustic measure of pitch

•  OUTCOME #3: Acoustic measure of jitter 

•  OUTCOME #4: Acoustic measure of duratioN

–  NONE of the outcomes were subjective.

–  ALL of the outcome measures were objective.

8.  Were reliability measures provided?  No

  Interobserver for analyzers?  No  

•  Intraobserver for analyzers?  No  

  Treatment fidelity for clinicians?  

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

—  What level of significance was required to claim significance?  p ≤ 0.01 

•  OUTCOME #1: Acoustic measure of loudness

     – Both PLVT and LSVT increased significantly from habitual level in all tasks

•  OUTCOME #2: Acoustic measure of pitch

     – LSVT increased significantly from habitual level in all tasks

     – PLVT increased significantly from habitual level only in reciting

•  OUTCOME #3: Acoustic measure of jitter

     – Both PLVT and LSVT decreased significantly from habitual level in the vowel task

     – The difference between PLVT and LSVT is not significant

•  OUTCOME #4: Acoustic measure of duration

      – Neither PLVT nor LSVT increased significantly from habitual level

—  What the statistical tests were used to determine significance?  Place xxx after any statistical test that was used to determine significance.  

•  ANOVA: (multivariate, repeated measures) 

•  Other:  There was also a Bonferoni Correction.

  Were confidence interval (CI) provided?  No __x___

10.  What is the clinical significance?  NA

11.  Were maintenance data reported?  No 

12.  Were generalization data reported?  Yes  

13.  Describe briefly the experimental design of the investigation.

• Thirty-two adults with PD were enrolled in this investigation by researchers from the Netherlands. The site was an outpatient clinic and the patients (Ps) were identified as consecutive Ps from the clinic’s patient rolls. The single experimental session for each P lasted approximately 30 minutes.

• The experiment involved 3 tasks and 3 conditions with each task/condition pairing being produced 2 times.

     – Tasks: 

          ∞ sustaining “ah” as long as possible, 

          ∞ reciting the months of the year, 

          ∞ reading a short passage in which the same 2 sentences form the middle of the passage were selected for analysis.

     – Conditions: 

          ∞ spontaneous speaking style (“the way you speak at home,” p. 498)           

          ∞ LSVT style (“think loud, think shout,” p. 499)

          ∞ PLVT style (“speak loud and low,” p. 499)

• Initially the experimenter gave the P a verbal direction but if the P was unsuccessful, the experimenter demonstrated the targeted behavior.

• The performance of the Ps was audiotaped for later acoustic analysis.

• The results were analyzed using multivariate analysis-of-variance with repeated measures.

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE:   NA

SUMMARY OF INTERVENTION

PURPOSE: To explore if instructing Ps with PD to “speak loud and low” limits the pitch rise associated with increased loudness.

POPULATION: Parkinson’s disease adults

MODALITY TARGETED: expression

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

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  jitter

DOSAGE: one, 30-minute session

MAJOR COMPONENTS: 2 interventions are briefly described: PLVT and LVST.

PLVT: 

• The clinician (C) directs the P to produce the target speaking “loud and low” (p. 499).

LSVT

• The clinician (C) directs the P to “think loud, think shout” (p. 499) when attempting to produce targets.

_______________________________________________________________


Solberg (2019)

April 15, 2020

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

CAPE-V =  Consensus Auditory-Perceptual Evaluation of Voice

EBP =  evidence-based practice

F0 =  Fundamental Frequency

Fftr =  Fundamental Frequency -Tremor Frequency

MPR =  Maximum Phonation Range

MPT =  Maximum Phonation Time

MT =  Music Therapy

NA =  not applicable

OMREX =  Oral Motor and Respiratory Exercises

P =  Patient or Participant

PD =  Parkinson’s disease

PFT =  Mean F0 Range

pmh =  Patricia  Hargrove, blog developer

SLP =  speech–language pathologist

TS =  Therapeutic Singing

 VHI =  Performance on the Voice Handicap Index

VIT =  Vocal Intonation Therapy

V-RQOL =  Voice -Related Quality of Life questionnaire

 

 

SOURCE:  Solberg, S. S. (2019). Neurologic music therapy to improve speaking voice in individuals with Parkinson’s disease. Master’s Thesis presented to the Graduate School at Appalachian State University (NC).  https://libres.uncg.edu/ir/asu/f/Solberg_Sarah_Thesis_Dec_2019.pdf

 

REVIEWER(S):  pmh

 

DATE:  April 8, 2020

 

ASSIGNED GRADE FOR OVERALL QUALITY:   C-    The highest possible grade based on the design of this investigation is    . The Assigned Grade for Overall Quality is based on the quality of the evidence; it does not represent a judgment about the intervention.

 

TAKE AWAY:  This single, small group investigation with pre-and post-intervention testing revealed that some of the targeted outcomes improved significantly following 6 weeks of intervention (1 hour per week) while 19 measures did not improve significantly (10 acoustic measures; 2 of 6 perceptual measures; 7 self rating measures). The only measures that yielded significant differences were perception of breathiness, pitch, loudness, and severity.

 

  1. What type of evidence was identified?
  • What was the type of evidence? Prospective, Single Group with Pre- and Post-Testing
  • What was the level of support associated with the type of evidence? Level = C+

 

                                                                                                           

  1. Group membership determination:
  • If there was more than one group, were participants (Ps) randomly assigned to groups? Not Applicable (NA)

 

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

                                                                    

  1. Was the group adequately described? Yes

– How many  Ps were involved in the study?

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

– CONTROLLED CHARACTERISTICS

  • age:45 to 80 years
  • cognitive skills:
  • first language:English
  • respiratory status:Within normal limits
  • current therapy:Not receiving speech-language pathology therapy or music therapy (MT) addressing voice problems
  • previous therapy:No MT addressing voice problems
  • diagnosis:All Ps were diagnosed with Parkinson’s disease (PD) at Stage 2 or 3 on the Hoehn and Yahr Scale
  • Other:Willing to participate in an intervention involving singing

 

– DESCRIBED CHARACTERISTICS:

  • age:69 to 80 years
  • gender:All male
  • Hoehn and Yahr Scale:2 (2 Ps) or 3 (4 Ps)
  • Social-Economic Status:
  • Domicile:all Ps resided within the community

 

–  Were the groups similar before intervention began? NA

                                                         

–  Were the communication problems adequately described? Yes

  • disorder type: dysarthria associated with Parkinson’s disease
  • other : all Ps had reported concern regarding changes in voice; the vocal characteristics of each of the Ps was described in the Participant section of the Method chapter.

 

  1. Was membership in the group 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

— ACOUSTIC MEASURES

  • OUTCOME #1: Jitter for sustained /a/
  • OUTCOME #2: Shimmer for sustained /a/
  • OUTCOME #3: Fundamental Frequency (F0) in Hz -Tremor Frequency (Fftr) for sustained /a/
  • OUTCOME #4: Maximum Phonation Time (MPT) for sustained /a/
  • OUTCOME #5: Maximum Phonation Range (MPR) for sustained /i/, lowest note
  • OUTCOME #6: MPR for sustained /i/, highest note
  • OUTCOME #7: Mean F0 for standardized read passage
  • OUTCOME #8: Mean F0 Range (PFT) for standardized read passage in semitones
  • OUTCOME #9: Mean intensity (in dB) for standardized read passage
  • OUTCOME #10: s/z ratio of sustained /s/ and /z/

 

–PERCEPTUAL MEASURES

  • OUTCOME #11: Performance on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)– Roughness
  • OUTCOME #12: Performance on the CAPE-V– Breathiness
  • OUTCOME #13: Performance on the CAPE-V– Strain
  • OUTCOME #14: Performance on the CAPE-V– Pitch
  • OUTCOME #15: Performance on the CAPE-V– Loudness
  • OUTCOME #16: Performance on the CAPE-V– Severity

 

–SELF REPORT MEASURES

  • OUTCOME #17: Performance on the Voice Handicap Index (VHI)—Functional subcategory
  • OUTCOME #18: Performance on the VHI—Physical subcategory
  • OUTCOME #19: Performance on the VHI—Emotional subcategory
  • OUTCOME #20: Performance on the VHI—Total score
  • OUTCOME #21: Performance on the Voice -Related Quality of Life (V-RQOL) questionnaire—Social domain
  • OUTCOME #22: Voice -Related Quality of Life (V-RQOL) questionnaire—Physical domain
  • OUTCOME #23: Voice -Related Quality of Life (V-RQOL) questionnaire—Total score

 

 The outcome measures that were subjective are

 

PERCEPTUAL MEASURES

  • OUTCOME #11: Performance on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)– Roughness
  • OUTCOME #12: Performance on the CAPE-V– Breathiness
  • OUTCOME #13: Performance on the CAPE-V– Strain
  • OUTCOME #14: Performance on the CAPE-V– Pitch
  • OUTCOME #15: Performance on the CAPE-V– Loudness
  • OUTCOME #16: Performance on the CAPE-V– Severity

 

SELF REPORT MEASURES

  • OUTCOME #17: Performance on the Voice Handicap Index (VHI)—Functional subcategory
  • OUTCOME #18: Performance on the VHI—Physical subcategory
  • OUTCOME #19: Performance on the VHI—Emotional subcategory
  • OUTCOME #20: Performance on the VHI—Total score
  • OUTCOME #21: Performance on the Voice -Related Quality of Life (V-RQOL) questionnaire—Social domain
  • OUTCOME #22: Voice -Related Quality of Life (V-RQOL) questionnaire—Physical domain
  • OUTCOME #23: Voice -Related Quality of Life (V-RQOL) questionnaire—Total score

 

–  The outcome measures that were objective are

  • OUTCOME #1: Jitter for sustained /a/
  • OUTCOME #2: Shimmer for sustained /a/
  • OUTCOME #3: Fundamental Frequency (F0) in Hz -Tremor Frequency (Fftr) for sustained /a/
  • OUTCOME #4: Maximum Phonation Time (MPT) for sustained /a/
  • OUTCOME #5: Maximum Phonation Range (MPR) for sustained /i/, lowest note
  • OUTCOME #6: MPR for sustained /i/, highest note
  • OUTCOME #7: Mean F0 for standardized read passage
  • OUTCOME #8: Mean F0 Range (PFT) for standardized read passage in semitones
  • OUTCOME #9: Mean intensity (in dB) for standardized read passage
  • OUTCOME #10: s/z ratio of sustained /s/ and /z/

 

  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/or the description of the results?

 

—  What level of significance was required to claim significance?  p = _0.05______

 

PRE AND POST TREATMENT ANALYSES

 

ACOUSTIC MEASURES

  • OUTCOME #1:Jitter for sustained /a/ — no significant difference in pre- to post-intervention scores
  • OUTCOME #2:Shimmer for sustained /a/– no significant difference in pre- to post-intervention scores
  • OUTCOME #3:Fundamental Frequency (F0) in Hz -Tremor Frequency (Fftr) for sustained /a/– no significant difference in pre- to post-intervention scores
  • OUTCOME #4:Maximum Phonation Time (MPT) for sustained /a/– no significant difference in pre- to post-intervention scores
  • OUTCOME #5:Maximum Phonation Range (MPR) for sustained /i/, lowest note– no significant difference in pre- to post-intervention scores
  • OUTCOME #6:MPR for sustained /i/, highest note– no significant difference in pre- to post-intervention scores
  • OUTCOME #7:Mean F0 for standardized read passage– no significant difference in pre- to post-intervention scores
  • OUTCOME #8:Mean F0 Range (PFT) for standardized read passage in semitones– no significant difference in pre- to post-intervention scores
  • OUTCOME #9:Mean intensity (in dB) for standardized read passage– no significant difference in pre- to post-intervention scores
  • OUTCOME #10: s/zratio of sustained /s/ and /z/– no significant difference in pre- to post-intervention scores

 

PERCEPTUAL MEASURES

  • OUTCOME #11: Performance on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)—Roughness– no significant difference in pre- to post-intervention scores
  • OUTCOME #12: Performance on the CAPE-V—Breathiness—there was a significant difference in pre-and post-intervention measures
  • OUTCOME #13: Performance on the CAPE-V—Strain– no significant difference in pre- to post-intervention scores
  • OUTCOME #14: Performance on the CAPE-V– Pitch—there was a significant difference in pre-and post-intervention measures
  • OUTCOME #15: Performance on the CAPE-V– Loudness—there was a significant difference in pre-and post-intervention measures
  • OUTCOME #16: Performance on the CAPE-V– Severity—there was a significant difference in pre-and post-intervention measures

 

SELF REPORT MEASURES

  • OUTCOME #17: Performance on the Voice Handicap Index (VHI)—Functional subcategory/– no significant difference in pre- to post-intervention scores
  • OUTCOME #18: Performance on the VHI—Physical subcategory/– no significant difference in pre- to post-intervention scores
  • OUTCOME #19: Performance on the VHI—Emotional subcategory/– no significant difference in pre- to post-intervention scores
  • OUTCOME #20: Performance on the VHI—Total score/– no significant difference in pre- to post-intervention scores
  • OUTCOME #21: Performance on the Voice -Related Quality of Life (V-RQOL) questionnaire—Social domain/– no significant difference in pre- to post-intervention scores
  • OUTCOME #22: Voice -Related Quality of Life (V-RQL) questionnaire—Physical domain/– no significant difference in pre- to post-intervention scores
  • OUTCOME #23: Voice -Related Quality of Life (V-RQOL) questionnaire—Total score/– no significant difference in pre- to post-intervention scores

 

–  What was the statistical test used to determine significance?  Wilcoxon

–  Were confidence interval (CI) provided?  No

 

  1. What is the clinical significance?

–  The investigators provided the folllowing evidence-based practice (EBP) measures for each outcome:Place xxx next to the EBP measure provided:  Effect Size (r)

 

Results of EBP testing and interpretations

ACOUSTIC MEASURES

  • OUTCOME #1:Jitter for sustained /a/ — r = 0.21 (small effect size)
  • OUTCOME #2:Shimmer for sustained /a/— r = 0.44 (small effect size)
  • OUTCOME #3:Fundamental Frequency (F0) in Hz -Tremor Frequency (Fftr) for sustained /a/— r = 0.27(small effect size)
  • OUTCOME #4:Maximum Phonation Time (MPT) for sustained /a/— r = 0.15 (small effect size)
  • OUTCOME #5:Maximum Phonation Range (MPR) for sustained /i/, lowest note— r = 0.53 (moderate effect size)
  • OUTCOME #6:MPR for sustained /i/, highest note — r = 0.42 (small effect size)
  • OUTCOME #7:Mean F0 for standardized read passage — r = 0.03 (negligible effect size)
  • OUTCOME #8:Mean F0 Range (PFT) for standardized read passage in semitones— r = 0.12 (small effect size)
  • OUTCOME #9:Mean intensity (in dB) for standardized read passage— r = 0.09 (small effect size)
  • OUTCOME #10: s/zratio of sustained /s/ and /z/— r = 0.31 (small effect size)

 

PERCEPTUAL MEASURES

  • OUTCOME #11: Performance on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)– Roughness— r = 0.33 (small effect size)
  • OUTCOME #12: Performance on the CAPE-V– Breathiness— r = 0.64 (moderate effect size)
  • OUTCOME #13: Performance on the CAPE-V– Strain— r = 0.31 (small effect size)
  • OUTCOME #14: Performance on the CAPE-V– Pitch— r = 0.64 (moderate effect size)
  • OUTCOME #15: Performance on the CAPE-V– Loudness— r = 0.64 (moderate effect size)
  • OUTCOME #16: Performance on the CAPE-V– Severity— r = 0.64 (moderate effect size)

 

SELF REPORT MEASURES

  • OUTCOME #17: Performance on the Voice Handicap Index (VHI)—Functional subcategory — r = 0.03 (negligible effect size)
  • OUTCOME #18: Performance on the VHI—Physical subcategory— r = 0.52 (moderate effect size)
  • OUTCOME #19: Performance on the VHI—Emotional subcategory— r = 0.03 (negligible effect size)
  • OUTCOME #20: Performance on the VHI—Total score— r = 0.43. (small effect size)
  • OUTCOME #21: Performance on the Voice -Related Quality of Life (V-RQOL) questionnaire—Social domain— r = 0.31 (small effect size)
  • OUTCOME #22: Voice -Related Quality of Life (V-RQOL) questionnaire—Physical domain— r = 0.00 (no effect size)
  • OUTCOME #23: Voice -Related Quality of Life (V-RQOL) questionnaire—Total score— r = 0.03 (negligible effect size)

 

  1. Were maintenance data reported? No

 

  1. Were generalization data reported? No

 

  1. Describe briefly the experimental design of the investigation.
  • Six Ps diagnosed with PD received a short course (6 weeks, 1 hour per week) of MT to improve voice problems associated with PD .
  • Ps were tested before and after the intervention using a variety ofacoustic, perceptual, and self-help measures.
  • . Data were analyzed using nonparametric statistics.

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  C-

 

SUMMARY OF INTERVENTION

PURPOSE:  To investigate the effectiveness of MT in improving voice of speakers with PD

POPULATION:  Parkinson’s disease; Adult

MODALITY TARGETED:  Expression

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: pitch, intonation, duration, loudness, phrasing

ELEMENTS OF PROSODY USED AS INTERVENTION: intonation/pitch, loudness, rhythm     

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  jitter, shimmer, s/z ratio, severity, roughness, strain, breathiness, self- perceptions of vocal function

DOSAGE:  1 hour per week of individual therapy for 6 weeks

ADMINISTRATOR:  Music Therapist

MAJOR COMPONENTS:  The investigator provided an extensive description of the intervention in Table 1 (pp. 41-42). A summary of the procedures are listed below.

 

  • The intervention was based on Neurologic Music Therapy procedures.

 

  • Each 1 hour long session consisted of 6 parts:

– Introductory Conversation (5 minutes)

∞ P and the clinician (C) discuss P’s current vocal changes and status.

∞ P and C review homework

– Vocal Intonation Therapy (VIT; 10 minutes)

∞ This part of NMT has 4 components:

  • Physical Warm-ups and 4-Point Grounding through Music
  • Breathing Exercises and Music
  • Articulation Exercises and Music (5 minutes)
  • Vocal Warm ups

– Therapeutic Singing (TS; 15 minutes)

∞ P sings 1 to 3 preferred songs. The focus of the singing is clear articulation and

phrasing coordinating breath and phonation.

– Oral Motor and Respiratory Exercises (OMREX; 10 minutes)

∞ P plays 2 or 3 preferred songs on the harmonica to improve breath support and

to practice controlled exhalation.

– Relaxation and Transition (5 minutes)

∞ Exercises to reduce tension and to facilitate relaxation were practiced

– Closing Conversation (2 minutes)

∞ C assigned homework and discussed with P strategies for extending what was

practiced to activities of daily living.

_____________________________________________________________

 

 


Spielman et al. (2007)

February 27, 2019

EBP THERAPY ANALYSIS

Treatment Groups

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

 Key:

C = Clinician

EBP = evidence-based practice

f =  female

LSVT = Lee Silverman Voice Treatment

m = male

NA = not applicable

P = Patient or Participant

PD = Parkinson’s disease

pmh =  Patricia  Hargrove, blog developer

SLP = speech–language pathologist

SPL = sound pressure level

VHI =  Voice Handicap Index, VHI)

 

SOURCE: Spielman, J., Ramig, L. O., Mahler, L. Halpern, A., & Gavin, W. J. (2007). Effects of an extended version of Lee Silverman Voice Treatment on voice and speech in Parkinson’s disease.  American Journal of Speech-Language-Pathology, 16, 95-107.

REVIEWER(S):  pmh

DATE:  February 21, 2019

ASSIGNED GRADE FOR OVERALL QUALITY:  B.The highest possible grade for this investigation, which is based on its experimental design, is B+. The Assigned Grade for Overall Quality should not be interpreted as a judgment of the quality of the intervention; instead it represents an evaluation of the evidence supporting the intervention.

TAKE AWAY: An extended version of Lee Silverman Voice Treatment  (LVST) increased sound pressure level (a performance similar to traditional LVST). Participants’ (Ps’) who received the extended version of LVST did not evidence significant improvements in self- ratings (as a group) on the Voice Handicap Index. However, some of the individual Ps did improve significantly from pre to post treatment. In addition, judges’ rating of the quality of the Ps’ speech revealed that Ps who received the extended version of LSVT and those who received traditional LSVT were judged to be significantly better communicators that Ps who did not receive treatment. 

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

–  There were 3 groups of Ps: one group of ‘new’ Ps and two groups of Ps who had been treated in a previous intervention (i.e., ‘old’ groups.)

–  No significant differences were identified among the 3 groups for age, years since diagnosis, Hoehn & Yahr stage, and severity of dysarthria.

  1. Was administration of intervention status concealed?
  • from participants? No
  • from clinicians? No
  • from analyzers? Yes 
  1. Were the groups adequately described? Yes

           How many  Ps were involved in the study?

  • total # of Ps: 44
  • # of groups:3
  • Names of groups and the # of participants (Ps) in each group:

∞  new group of Ps receiving Lee Silverman Voice Therapy (LSVT) extended over 8 weeks or LVST-X (X- PD)  = 15

∞  group from previous investigation receiving standard LVST (T-PD) =  14

∞  group from previous investigation receiving not receiving treatment (NT-PD)  =  15

–  CONTROLLED CHARACTERISTICS:

  • cognitive skills:all Ps lived independently and were about to complete documentation associated with the investigation
  • diagnosis: Parkinson’s disease (PD)
  • medication status:medication of all Ps was stable
  • physical status:excluded Ps for whom exertion associated with high-effort voice therapy would be inappropriate

–  DESCRIBED CHARACTERISTICS:

  • age:

∞ X-PD =  45 years – 82 years (mean = 67.2)

∞ T-PD =  51 years – 80 years (mean = 67.9)

∞ NT-PD =  64 years – 91 years (mean 71.2)

  • gender:

∞ X-PD =  10 male (m); 5 female (f)

∞ T-PD =  7m; 7f

∞ NT-PD =  7m; 8f

  • years since diagnosis:

∞ X-PD =  0.5 years – 11 years (mean 4.8)

∞ T-PD =  1.5 years – 20 years (mean 8.6; 1 missing data point)

∞ NT-PD =  0.5 years – 19 years (mean 7.4; 1 missing data point)

  • Hoehn & Yahr stage of PD:

∞ X-PD =  2-3 (mean 2.5; 2 missing data points)

∞ T-PD =  2-5 (mean 3.1; 7 missing data points)

∞ NT-PD =  1-3 (mean 2.2; 2 missing data points)

  • severity of dysarthria:

∞ X-PD =  1-5 (mean 2.6)

∞ T-PD =  0-5 (mean 2.9)

∞ NT-PD =  0-4 (mean 2.3)

–   Were the groups similar before intervention began? Yes                                                          

–  Were the communication problems adequately described?  Yes

  • disorder type: All Ps were judged by a panel of speech-language pathologist (SLPs) to produce speech and voice that was characteristic of PD.  Some of thos characteristics include

∞  reduced loudness

∞  breathiness

∞  monopitch

∞  imprecise articulation

∞  hoarseness

∞  strained voice quality

∞  fast rate

∞  palilalia

∞  slow rate

∞  pitch breaks

  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?Yes
  • 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, the treatment time was essentially the same in the X-PD and T-PD groups but the X-PD sessions tended to go longer because they had more homework.  (Because the X-PD group extended over 2 months they had more homework.)
  1. Were the outcomes measure appropriate and meaningful?  Yes

– OUTCOMES                                                                                   

  • OUTCOME #1:  Sound pressure level in 4 tasks

∞ phonation

∞  reading

∞  picture description

∞  conversation

  • OUTCOME #2:  P’s perception of voice (Voice Handicap Index, VHI)
  • OUTCOME #3:  Listener’s perception of changes in voice quality, clarity, rate, intonation, and naturalness

–  The outcome measures that are subjective are

  • OUTCOME #2:P’s perception of voice (Voice Handicap Index, VHI)
  • OUTCOME #3:Listener’s perception of changes in voice quality, clarity,

rate, intonation, and naturalness

  The outcome measures that are objective are

  • OUTCOME #1:Sound pressure level in 4 tasks

∞  phonation

∞  reading

∞  picture description

∞  conversation                                       

  1. Were reliability measures provided?

   Interobserver for analyzers?  Variable

  • OUTCOME #3:  Listener’s perception of changes in voice quality, clarity, rate, intonation, and naturalness

∞  intraclass correlation coefficient (Cronbach’s) = 0.90

–  but there were significant differences among judges 

–  Intraobserver for analyzers?  Variable

  • OUTCOME #3:  Listener’s perception of changes in voice quality, clarity,

rate, intonation, and naturalness

     –  ∞ average correlation coefficient (r) was 0.90, range 0.88 to 0.98

–  Treatment fidelity for clinicians?  No   

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

–  What level of significance was required to claim significance?  p = 0.0021

TREATMENT, COMPARISON, AND NO TREATMENT GROUP ANALYSES

  • OUTCOME #1: Sound pressure level in 4 tasks

∞  phonation

  • significant improvement for X-PD groups from pre to post treatment assessment and from pretreatment to follow up
  • no significant differences between X-PD and T-PD before and after treatment

     ∞ reading

  • significant improvement for X-PD groups from pre to post treatment and from pretreatment to follow up
  • no significant differences between X-PD and T-PD before and after treatment

∞  picture description

  • significant improvement for X-PD groups from pre to post treatment and from pretreatment to follow up
  • significant differences between X-PD and T-PD after treatment but no significant difference for pretreatment

∞ conversation

  • significant improvement for X-PD groups from pre to post treatment
  • no significant differences between X-PD and T-PD before and after treatment

 

  • OUTCOME #2:P’s perception of voice (Voice Handicap Index, VHI)

∞  no significant difference in LVST-X group’s scores from pre to post treatment

 

  • OUTCOME #3:Listener’s perception of changes in voice quality, clarity, rate, intonation, naturalness

     ∞  both treatment groups (X-PD, T-PD) were significantly better than the group that did not receive treatment (NT-PD).

 

–  Were confidence interval (CI) provided?  No

 

  1. What is the clinical significance
  • The investigators provided the following EBP: ETA
  • Results of EBP testing and the interpretation:
  • OUTCOME #1:Sound pressure level in 4 tasks: phonation, reading, picture description, and conversation

∞  eta for time of assessment (pretreatment, posttreatment, and follow-up) was 0.90 (large effect)

 

  1. Were maintenance data reported? Yes. There were significant difference for SLP for pretreatment  and follow-up measures for phonation, reading, and picture description but not for conversation.

 

  1. Were generalization data reported? Yes
  • Outcomes 2 and 3 can be considered generalization outcomes.

 

  1. Describe briefly the experimental design of the investigation.
  • The investigators selected 15 Ps with PD (12 completed the investigation) who received an extended version of LSVT. This was labeled X-PD and outcomes were compared them to 2 groups from a previous investigation:T-PD (the Ps had received traditional LSVT) and NT-PD (this was a control in which Ps did not receive LSVT).

 

  • LSVT and LSVT-X treatment protocols were identical except that treatment for LSVT-X was administered 2 times a week and lasted for 8 weeks. Also, the investigators noted that sessions for the X-PD tended to go overtime because the clinicians spent more time reviewing homework as there were more days that Ps were assigned homework.

 

  • Investigators assessed Ps prior to treatment, immediately after treatment, and 6 months after the completion of treatment.

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  B

 

SUMMARY OF INTERVENTION

PURPOSE: To investigate the effectiveness of an extended version of LSVT

POPULATION:  Parkinson’s disease; adults

MODALITY TARGETED: production

ELEMENTS OF PROSODY USED AS INTERVENTION (part of independent variable:  loudness, pitch change

ASPECT OF PROSODY TARGETED:   Loudness

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  perception of voice and speech

DOSAGE:

  • traditional Lee Silverman Voice Treatment (LVST) = 4 one-hour individual sessions for 4 weeks (16 sessions); daily homework (5 to 10 minutes a day on treatment days; 20-30 minutes on nontreatment days)
  • LVST extended version (LVST-X) = 2 one-hour individual sessions for 8 weeks (16 sessions); daily home work (5 to 10 minutes a day; 20-30 minutes on nontreatment days)

ADMINISTRATOR:  SLP trained in LSVT

MAJOR COMPONENTS:

  • Common Major Components of LSVT and LSVT-X

– individual sessions

– one hour sessions

– 16 sessions

– sessions started with review of homework

– tasks were hierarchical

– Sessions were divided into practice using a louder voice and carryover activities

– LOUDER VOICE:

∞ the target is the production of a louder voice using healthy strategies

∞ 15 repetitions of “ah” in a loud voice using high effort

∞ 15 repetition each of high pitch glides and low pitch glides

∞ 5 repetitions of 10 sentences using the louder voice produced with healthy strategies

– CARRY OVER:

∞ Use of the louder, healthy voice for the production of sentences that increase in length and complexity.

– Homework:  Clinicians assigned homework to the Ps (5 to 10 minutes a day; 20-30 minutes on nontreatment days). Homework consisted of worksheets with carryover activities and reading assignments.

 

  • Different Major Components of LSVT and LSVT-X

–  Because LSVT-X lasted for 8 weeks compared to LSVT’s 4 weeks more homework was assigned to the LSVT-X group (96 versus 40 assignments.)

–  The investigators noted that sessions for the X-PD tended to go overtime  because the clinicians spent more time reviewing homework as there were more days that Ps were assigned homework.

_______________________________________________________________

 

 


Halpern et al. (2012)

December 1, 2017

EBP THERAPY ANALYSIS

Treatment Groups

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

Key:

C = Clinician

CI = Confidence Interval

EBP = evidence-based practice

f = female

LSVT Companion = Lee Silverman Voice Treatment Companion

LSVT Loud = Lee Silverman Voice Treatment Loud

m = male

NA = not applicable

P = Patient or Participant

PD = Parkinson disease

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

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

 

REVIEWER(S): pmh

 

DATE: November 29, 2017

 

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

 

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

 

 

  1. What type of evidence was identified?

                                                                                                           

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

                                                                                                          

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

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

 

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

                                                                    

 

  1. Were the groups adequately described? Yes

– How many Ps were involved in the study?

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

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

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

∞ Historical Group = 13

 

— CONTROLLED CHARACTERISTICS

  • cognitive skills: no evidence of dementia

 

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

 

  • diagnosis: Idiopathic PD

 

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

 

— DESCRIBED CHARACTERISTICS:

  • age:

∞ Immediate Group = mean 65.8

∞ Delayed Group = mean 63.3

∞ Historical Group =   mean 68.5

 

  • gender:

∞ Immediate Group = 4f, 4m

∞ Delayed Group = 4f, 4m

∞ Historical Group = 6f, 7m

 

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

∞ Immediate Group = 2.3

∞ Delayed Group = 2.0

∞ Historical Group = 2.7

 

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

 

  • race: All Ps identified as white.

 

  • ethnicity: All Ps identified as not Hispanic or Latino

 

  • years post diagnosis:

∞ Immediate Group = 4.4

∞ Delayed Group = 4.7

∞ Historical Group = 8.5

 

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

∞ Immediate Group = 1.9

∞ Delayed Group = 2.0

∞ Historical Group = not available

 

–   Were the groups similar before intervention began? Yes

                                                         

– Were the communication problems adequately described? Yes

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

 

 

  1. Was membership in groups maintained throughout the study?
  • Did each of the groups maintain at least 80% of their original members? Yes
  • Were data from outliers removed from the study?

Yes ____     No __x___     Unclear ____

 

 

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

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

OUTCOMES:

                                                                                                             

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

 

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

 

  • OUTCOME #3: SPL during a monologue

 

  • OUTCOME #4: SPL during a picture description task

 

  • OUTCOME #5: SPL during a fluency task

 

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

 

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

 

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

 

 

– The outcome measures that were objective are

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

 

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

 

  • OUTCOME #3: SPL during a monologue

 

  • OUTCOME #4: SPL during a picture description task

 

  • OUTCOME #5: SPL during a fluency task

 

– The outcome measures that were subjective are

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

 

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

 

                                         

  1. Were reliability measures provided?

                                                                                                            

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

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

 

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

 

– Intraobserver for analyzers? Yes, for one outcome.

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

 

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

 

 

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

 

Summary Of Important Results

 

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

 

 

TREATMENT/NO TREATMENT GROUP ANALYSES

 

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

 

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

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

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

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

 

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

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

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

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

 

  • OUTCOME #3: SPL during a monologue

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

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

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

 

  • OUTCOME #4: SPL during a picture description task

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

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

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

 

  • OUTCOME #5: SPL during a fluency task

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

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

∞ Historical Group = data not available for this outcome

 

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

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

∞ Historical Group = data not available for this outcome

 

 

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

∞ Immediate Group =

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

∞ Delayed Group =

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

∞ Historical Group = data not available for this outcome

 

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

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

∞ Historical Group =   data not available for this outcome

 

– What was the statistical test used to determine significance?

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

 

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

 

– What was reported CI?

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

 

 

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

 

 

  1. Were maintenance data reported? Yes

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

 

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

 

 

  1. Were generalization data reported? Yes

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

 

 

  1. Describe briefly the experimental design of the investigation.

 

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

 

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

 

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

 

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

 

–  All Ps were tested during 3 periods:

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

 

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

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: B

 

 

 

SUMMARY OF INTERVENTION

 

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

 

POPULATION: Parkinson disease; Adults

 

MODALITY TARGETED: expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness

 

ELEMENTS OF PROSODY USED AS INTERVENTION: Loudness

 

OTHER TARGETS: perception of improvement and usability

 

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

 

ADMINISTRATOR: SLP qualified to administer LSVT-LOUD

 

MAJOR COMPONENTS:

 

 

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

 

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

 

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

 

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

 

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

 

 

_______________________________________________________________

 

 


Diekema (2016)

March 23, 2017

ANALYSIS GUIDELINES

Comparison Research

 

KEY: 

CS = Clear Speech

eta = partial eta squared

f = female

fo = fundamental frequency

m = male

MLU = mean length of utterance

NA = Not Applicable

P = participant or patient

PD = Parkinson Disease

pmh = Patricia Hargrove, blog developer

S = segment

SD = standard deviation

SLP = speech-language pathologist

ST = semitones

 

SOURCE: Diekema, E. (2016). Acoustic Measurements of Clear Speech Cue Fade in Adults with Idiopathic Parkinson Disease. (Electronic Thesis or Dissertation). Bowling State University, Bowling Green, OH. Retrieved from https://etd.ohiolink.edu/

 

REVIEWER(S): pmh

 

DATE: March 17, 2017

 

ASSIGNED GRADE FOR OVERALL QUALITY: Not graded. This investigation is not classified as an intervention study; rather it is an investigation of learning behavior in adults with Parkinson Disease (PD.)

 

TAKE AWAY: This investigation is not classified as an intervention study; rather it is an investigation of learning behavior in adults with Parkinson Disease (PD.) The results, however, can inform therapeutic practice. Speech samples of 12 adults with PD were recorded while they read aloud part of the Rainbow Passage following cues to use Clear Speech (CS) to explore whether the selected prosodic changes would be maintained after the CS cue. The results indicated that improvements in the following measures decreased throughout the passage suggesting that the gains from CS cues were not maintained: speech rate, articulation rate, percent pause time, fo variability, and intensity throughout the passage. However, gains in the following measures were maintained throughout the passage: intensity associated with word stress and mean fo . The investigator suggested that when using CS with adults with PD, clinicians should consider modifications to enhance the cues effectiveness over time.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of design? Retrospective, Single Group with Multiple Measurements of Selected Outcomes

 

  • What was the focus of the research? Clinically Related

                                                                                                           

  • What was the level of support associated with the type of evidence? Level = not graded.

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there were 2 or more groups, were participants randomly assigned to groups? Not Applicable (NA), there was only one group.

                                                                   

 

  1. Were experimental conditions concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from administrators of experimental conditions? No

                                                                    

  • from analyzers/judges? No

                                                                    

 

  1. Was the group adequately described? No

 

– How many participants were involved in the study?

 

  • total # of Ps: 12
  • # of groups: 1:
  • Did the group maintain membership throughout the investigation? Yes

 

 

CONTROLLED CHARACTERISTICS

  • diagnosis: idiopathic PD • gender:

 

DESCRIBED CHARACTERISTICS

  • age: 55- 84 years (mean = 73 years)
  • gender: 6m; 6f
  • medication: All Ps were receiving medications

 

  • Were the groups similar? NA, there was only one group

 

  • Were the communication problems adequately described? No

 

  • disorder type: dysarthria associated with PD

 

 

  1. What were the different conditions for this research?

                                                                                                             

  • Subject (Classification) Groups?

                                                               

  • Experimental Conditions? No

 

  • Criterion/Descriptive Conditions? Yes

 

  • Outcomes were for measured for the 5 segments of the read aloud versions of the Rainbow Passage of approximately 25 syllables each:

– Segment (S) 1

– S2

– S3

– S4

– S5

 

 

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

 

 

  1. Were dependent measures appropriate and meaningful? Yes

                                                                                                             

– OUTCOMES

 

  • OUTCOME #1: Average speech rate
  • OUTCOME #2: Average articulation rate
  • OUTCOME #3: Percent pause time
  • OUTCOME #4: Average fundamental frequency (fo) in semitones (ST) for the segment
  • OUTCOME #5: Average fo comparison (difference) for beginning (S1) and end (S5) of passage
  • OUTCOME #6: Coefficient of variation of fo for each segment
  • OUTCOME #7: Standard deviation (SD) in ST for each segment
  • OUTCOME #8: Differences in intensity between the first “rain” and first “bow” and last “rain” and “bow” for each participant (P)
  • OUTCOME #9: Difference in intensity from beginning to end of the Rainbow Passage (i.e., S1 “rain” versus S5 “rain” and S1 “bow” versus S5 “bow”)

 

None of the dependent measures were subjective.

 

– All of the dependent/ outcome measures were objective.

 

 

  1. Were reliability measures provided?

                                                                                                            

  • Interobserver for analyzers?   No

 

  • Intraobserver for analyzers? No

 

  • Treatment or test administration fidelity for investigator? No

 

 

  1. Description of design:
  • The investigator analyzed pre-existing speech samples of 12 Ps diagnosed with PD.
  • The samples consisted of segments of the Rainbow Passage which the Ps had been directed to read aloud as if listeners where having trouble with understanding or hearing.
  • To analyze the samples, the investigator divided the passage into 5 segments of 25 syllables each with the exception of S5 that had 26 syllables. (The purpose of the segmentation was to enable the investigator to answer her question regarding the fading of the effectiveness of CS cues. Fading would be indicated by changes in the acoustic outcome measures over the 5 segments.)
  • Although there were an equal number of syllables in each segment, there were an unequal number of natural pauses in the segments:

– S1 = 2 pauses

– S2 = 1 pause

– S3 = 2 pauses

– S4 = 3 pauses

– S5 = 1 pause

 

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

 

  • RESULTS:

 

 

  • OUTCOME #1: Average speech rate

– With the exception of S4, speech rate increased as the Ps progressed through the passage (i.e., there were significant difference among segments.)

     – From S1 to S5 across all Ps, there was an average increase in speech rate of 22%.

   – This suggests that the CS cue faded.

 

  • OUTCOME #2: Average articulation rate

– With the exception of S4, articulation rate increased as the Ps progressed through the passage (i.e., there were significant difference among segments.)

     – From S1 to S5 across all Ps, there was an average increase in speech rate of 18%.

   – This suggests that the CS cue faded.

 

  • OUTCOME #3: Percent pause time

     – Although there was a significant difference among the segments, the changes in pause time were not consistent. (This could be because of the differences in the number of natural pauses in the segments.)

     – The comparisons that were significant included

  • S1 (2 pauses) versus S4 (3 pauses)
  • S2 (1 pause) versus S4 (3 pauses)
  • S3 (2 pauses) versus S5 (1 pause)
  • S4 (3 pauses) versus S5 (1 pause)

   – This suggests that the CS cue faded.

 

  • OUTCOME #4: Average fundamental frequency (fo) in semitones (ST) for the segment

– The average fo (in ST) tended to decrease as Ps progressed through the passage but the investigator noted that the change in ST was only 1 ST and was unlikely to be perceivable.

   – This suggests that the CS cue was maintained.

 

  • OUTCOME #5: Average fo comparison (difference) for beginning (S1) and end (S5) of passage

– The average fo (in semitones) decreased in S1 compared to S5 but the investigator noted that the change in ST was only 1 ST and was unlikely to be perceivable

   – This suggests that the CS cue was maintained.

 

  • OUTCOME #6: Coefficient of variation of fo for each segment

     – Although Ps patterns of fo variation did not change in a linear manner. The highest variation was in S1 and the smallest was in S5.

   – This suggests that the CS cue faded.

  • OUTCOME #7: Standard deviation (SD) in ST for each segment

     – Ps patterns of fo variation were more linear than for Outcome #6.

     – The variation tended to decrease from S1 to S5.

   – This suggests that the CS cue faded.

 

  • OUTCOME #8: Differences in intensity between the first “rain” and first “bow” and last “rain” and “bow” for each participant (P) [i.e., stress related intensity]

– There were no significant differences for these comparisons suggesting the original CS cue was maintained (i.e., it did not fade.)

 

  • OUTCOME #9: Difference in intensity from beginning to end of the Rainbow Passage (i.e., S1 “rain” versus S5 “rain” and S1 “bow” versus S5 “bow”) [i.e., intensity throughout the sample]

     Overall, there were significant difference in the first and last productions of “rain” and the first and last productions of “bow.”

   – This suggests that the CS cue faded.

 

– What were the statistical tests used to determine significance?

  • t-test
  • ANOVA
  • MANOVA
  • Bonferroni correction

 

– Were effect sizes provided? Yes, but since this is not an intervention study, it will not be reported in this review.

 

– Were confidence interval (CI) provided? No

 

 

  1. Summary of correlational results: NA

 

 

  1. Summary of descriptive results: Qualitative research NA

 

 

  1. Brief summary of clinically relevant results:
  • The strength of the CS cue was maintained only for measures of intensity associated with word stress and mean fo throughout the 5 segments of the Rainbow Passage (Outcomes 4, 5, and 8.)
  • For the following measures, the strength of the CS cue faded during the reading of the Rainbow Passage: speech rate, articulation rate, percent pause time, fo variability, and intensity throughout the passage (Outcomes 1, 2, 3, 6, 7, and 9.)
  • The investigator suggested that when using CS with adults with PD, clinicians should consider modifications to enhance the cues temporal effectiveness.

 

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: no grade, this is an not an intervention investigation.

 

 

 

 


Theodoros et al. (2016)

February 11, 2017

 

EBP THERAPY ANALYSIS

Treatment Groups

 

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

 

Key:

C = Clinician

DIP = Dysarthria Impact Profile

EBP = evidence-based practice

f = female

FTF = face-to-face intervention

m = male

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = Patient or Participant

PD =   Parkinson’s Disease

PDQ-39 = Parkinson’s Disease Questionnaire-39

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

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

 

REVIEWER(S): pmh

 

DATE: February 7, 2017

 

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

 

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

 

 

  1. What type of evidence was identified?

                                                                                                           

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

                                                                                                           

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

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

                                                                   

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from clinicians? No

                                                                    

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

                                                                    

 

  1. Were the groups adequately described? Yes

 

– How many Ps were involved in the study?

 

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

 

– CONTROLLED CHARACTERISTICS

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

 

– DESCRIBED CHARACTERISTICS

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

* = no significant difference among the 3 grous

 

–   Were the groups similar before intervention began?

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

                                                         

– Were the communication problems adequately described? No

  • disorder type: dysarthria associated with PD

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

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

Yes _x__     No ___     Unclear

 

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

     – speech intelligibility

     – articulatory precision

     –   ease of understanding by partner

     – sustained phonation

     – loudness

     – articulatory precision

   – rating of communication on PDQ 39

 

 

  1. Were the groups controlled acceptably? Yes

 

                                                                                                             

  • Was there a no intervention group? No  

                                   

  • Was there a foil intervention group? No

                                   

  • Was there a comparison group? Yes

 

  • Was the time involved in the comparison and the target groups constant? Yes

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

OUTCOMES

 

ACOUSTIC MEASURES:

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

 

PERCEPTUAL MEASURES:

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

 

QUALITY OF LIFE MEASURES

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

 

 

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

 

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

                                         

 

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Yes

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

 

– Intraobserver for analyzers? Yes

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

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

 

Treatment fidelity for clinicians? No

 

 

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

 

SUMMARY OF RESULTS

 

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

 

 

TREATMENT AND COMPARISON TREATMENT GROUP ANALYSES

 

ACOUSTIC MEASURES:

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

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

 

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

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

 

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

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

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

 

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

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

 

 

PERCEPTUAL MEASURES:

  • OUTCOME #5: Improved perceived intelligibility

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

 

  • OUTCOME #6: Improved perceived pitch variability

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

 

  • OUTCOME #7: Improved perceived loudness

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

 

  • OUTCOME #8: Improved perceived vocal roughness

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

 

  • OUTCOME #9: Improved perceived articulatory precision

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

 

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

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

 

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

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

 

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

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

 

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

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

 

  • OUTCOME #14: Improved overall rating of communicative partner

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

 

 

QUALITY OF LIFE MEASURES

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

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

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

 

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

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

 

 

– What statistical tests were used to determine significance?

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

 

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

 

 

  1. What is the clinical significance? NA

 

 

  1. Were maintenance data reported? No

 

  1. Were generalization data reported? Yes

 

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

– Ease of understanding

– Repetition requests

– Overall rating by communicative partner

– P’s acceptance of his/her dysarthria

– Overall DIP score

 

 

  1. Describe briefly the experimental design of the investigation.

 

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

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

– 1 group of Ps from Rural areas

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

– Acoustic measures

– Perceptual measures

– Quality of Life measures

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: A-

 

 

 

SUMMARY OF INTERVENTION

 

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

 

POPULATION: Parkinson’s Disease; Adults

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, pitch variation

 

ELEMENTS OF PROSODY USED AS INTERVENTION: loudness

 

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

OTHER TARGETS: Quality of life indicators

 

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

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

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

– LVST summary

– Online procedures

– FTF procedures

 

LVST SUMMARY

 

  • Purpose of LVST: to increase loudness and phonatory effort

 

  • Structure of Sessions:

– Repetitive Drills

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

 

– Functional Speech Activities

 

– Assignment of Homework

 

 

ONLINE PROCEDURES

 

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

 

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

 

 

FTF PROCEDURES

 

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

 


Herd et al. (2012)

April 7, 2016

SECONDARY REVIEW CRITIQUE

 

 

KEY:

 

C = clinician

CI = confidence interval

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

SR = Systematic Review

 

 

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

 

Reviewer(s): pmh

 

Date: April 4, 2016

 

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

 

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

 

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

 

 

What type of secondary review? Meta Analysis

 

 

  • Were the results valid? Yes

 

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

 

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

 

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

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

 

– Did the sources involve only English language publications? Unclear

 

– Did the sources include unpublished studies? Yes

 

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

 

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

 

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

 

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

 

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

 

– Were interrater reliability data provided? No

 

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

 

– Were assessments of sources sufficiently reliable? Yes

 

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

 

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

 

– Were there a sufficient number of sources? No.

 

  1. Description of outcome measures:

 

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

 

 

  1. Description of results:

 

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

 

  • Summarize overall findings of the secondary research:

 

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

 

  • Outcome #1: Improved measures of loudness

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

 

  • Outcome #2: Improved measures of monotonicity

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

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

    

  • Outcome #3: Improved measures of pitch

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

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

 

  • Outcome #4: Improved ratings of speech impairment

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

 

– Were the results precise? Yes

 

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

 

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

 

– Were the results in the same direction? Yes

 

– Did a forest plot indicate homogeneity? Yes

 

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

 

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

– Were negative outcomes noted? Yes

                                                                                                                   

 

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

 

 

  • Were generalization data reported?  Unclear

 

 

 

SUMMARY OF INTERVENTION

 

 

Population: Parkinson’s Disease; Adults

 

Prosodic Targets: loudness, intonation (monotonicity), pitch

 

Nonprosodic Targets: speech impairment

 

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

 

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

 

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

 

  • Group treatment focused on pitch and loudness.

 

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

 

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

 

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

 

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

 

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

 

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

 

 

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

 

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

 

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

 

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

 

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

 

 

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

 

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

 

  • The sessions were individual sessions.

 

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

 

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

 

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

Martens et al. (2015)

November 30, 2015

EBP THERAPY ANALYSIS

Treatment Groups

 

 

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

 

Key:

C = Clinician

EBP = evidence-based practice

f = female

Fo-max last syllable = maximum fundamental frequency of the last syllable (Fo-max last syllable)

Fo-max median= median maximum fundamental frequency

m = male

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

SPRINT therapy = speech rate and intonation therapy

 

 

SOURCE: Martens, H., Van Nuffelen, G., Dekens, T., Hernández-Díaz Huicia, M., Arturo Kairuz Hernández-Díaz, M., De Letter, M., &, De Bodt, M. (2015). The effect of intensive speech rate and intonation therapy of intelligibility of Parkinson’s disease. Journal of Communication Disorders, 58, 91 -105.

 

 

REVIEWER(S): pmh

 

DATE: November 23, 2015

 

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

 

TAKE AWAY: Eleven Dutch speakers diagnosed with hypokinetic dysarthria due to Parkinson’s disease received an intensive course of speech therapy focusing on rate and intonation to improve intelligibility. Intelligibility improved significantly with a large effect size. Several other measures also improved including measures associated with the perception of intonation representing questions or statements, the frequency of pauses, and maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in reading and repetition tasks.

 

 

  1. What type of evidence was identified?

                                                                                                           

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

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

                                                                    

 

  1. Were the groups adequately described? Yes

 

How many Ps were involved in the study?

  • total # of Ps: 11 (from a volunteer group of 42)
  • # of groups: 1

 

The P characteristics that were controlled included

  • age:
  • gender:
  • diagnosis: idiopathic Parkinson’s disease (PD)
  • neurological status: no comorbid neurological disorders
  • motivation: following screening interview still indicated he/she was willing to participate in rigorous intervention
  • vision: determined to be sufficient during screening interview
  • hearing: determined to be sufficient during screening interview
  • cognitive skills: determined to be sufficient during screening interview
  • language: determined to be sufficient during screening interview
  • reading: determined to be sufficient during screening interview
  • intelligibility: reduced intelligibility on the Dutch Sentence Intelligibility Assessment (<90% intelligible)        
  • receptive prosody skills: score ≥ 80% on test, if necessary after a 1 hour receptive prosody training session

 

The P characteristics that were described included

  • age: 52 to 94 years; mean 70 years
  • gender: 7m; 4f
  • anti PD medication: All Ps were receiving anti PD medications; the specific medications for each P is listed in Table 1.  
  • received Deep Brain Stimulation: 4 yes; 7 no
  • previous speech therapy: 5 Ps had a history of speech therapy for loudness and/or rate
  • current speech therapy: suspended during the intervention
  • years since diagnosis: 4 to 29 years; mean 16 years
  • language spoken: Dutch

 

Were the groups similar before intervention began? NA

                                                         

–  Were the communication problems adequately described? Yes

  • disorder type: hypokinetic dysarthria
  • functional level:

     – severity of dysarthria ranged from mild (2 Ps) to moderate (8 Ps) with 1 P undermined

– sentence intelligibility ranged from 64% to 90%

 

 

  1. Was membership in groups maintained throughout the study?

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

Were data from outliers removed from the study? No

 

 

  1. Were the groups controlled acceptably? NA

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

–   The outcomes (dependent variables) were

 

PERCEPTUAL MEAURES:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences
  • OUTCOME #2: Improved intonation of questions and statements in reading and repetition
  • OUTCOME #3: Improved intonation of questions in reading and repetition
  • OUTCOME #4: Improved intonation of statements in reading and repetition
  • OUTCOME #5: Improved intonation of questions and statements in reading
  • OUTCOME #6: Improved intonation of questions and statements in repetitions

 

AUTOMATED MEASURES:

  • OUTCOME #7: Improved speech rate (number of syllables per second including pauses) in a read passage
  • OUTCOME #8: Improved speech rate (number of syllables per second including pauses) in story telling
  • OUTCOME #9: Improved speech rate (number of syllables per second including pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #10: Improved articulation rate (number of syllables per second excluding pauses) in a read passage
  • OUTCOME #11: Improved articulation rate (number of syllables per second excluding pauses) in story telling
  • OUTCOME #12: Improved articulation rate (number of syllables per second excluding pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #13: Increased mean pause time in read passages
  • OUTCOME #14: Increased mean pause time in story telling
  • OUTCOME #15: Increased mean pause time during the intelligibility test—read nonsense test
  • OUTCOME #16: Increased mean number of pauses in read passages
  • OUTCOME #17: Increased mean number of pauses in story telling
  • OUTCOME #18: Increased mean number of pauses during the intelligibility test—read nonsense test

 

ACOUSTIC MEASURES:

  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence repetition task
  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence repetition task
  • OUTCOME #21: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence reading task  
  • OUTCOME #22: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence repetition task  
  • OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task  
  • OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task  

 

– The outcome measures that are subjective are

 

PERCEPTUAL MEAURES:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences
  • OUTCOME #2: Improved intonation of questions and statements in reading and repetition
  • OUTCOME #3: Improved intonation of questions in reading and repetition
  • OUTCOME #4: Improved intonation of statements in reading and repetition
  • OUTCOME #5: Improved intonation of questions and statements in reading
  • OUTCOME #6: Improved intonation of questions and statements in repetitions

 

 

– The objective outcome measures are

 

AUTOMATED MEASURES:

  • OUTCOME #7: Improved speech rate (number of syllables per second including pauses) in a read passage
  • OUTCOME #8: Improved speech rate (number of syllables per second including pauses) in story telling
  • OUTCOME #9: Improved speech rate (number of syllables per second including pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #10: Improved articulation rate (number of syllables per second excluding pauses) in a read passage
  • OUTCOME #11: Improved articulation rate (number of syllables per second excluding pauses) in story telling
  • OUTCOME #12: Improved articulation rate (number of syllables per second excluding pauses) during the intelligibility test –read nonsense syllables
  • OUTCOME #13: Increased mean pause time in read passages
  • OUTCOME #14: Increased mean pause time in story telling
  • OUTCOME #15: Increased mean pause time during the intelligibility test—read nonsense test
  • OUTCOME #16: Increased mean number of pauses in read passages
  • OUTCOME #17: Increased mean number of pauses in story telling
  • OUTCOME #18: Increased mean number of pauses during the intelligibility test—read nonsense test

 

ACOUSTIC MEASURES:

  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence repetition task
  • OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence reading task
  • OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence repetition task
  • OUTCOME #21: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence reading task  
  • OUTCOME #22: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence repetition task  
  • OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task  
  • OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task  

 

                                         

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Yes

  • Combined reliability for Perceptual Measures (Outcomes #1 through #6 which are listed below the reliability data) was high:

– Pre-treatment Intraclass Correlation Coefficient = 0.831

– Post-treatment Intraclass Correlation Coefficient = 0.933

OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences

OUTCOME #2: Improved intonation of questions and statements in reading and repetition

OUTCOME #3: Improved intonation of questions in reading and repetition

OUTCOME #4: Improved intonation of statements in reading and repetition

OUTCOME #5: Improved intonation of questions and statements in reading

OUTCOME #6: Improved intonation of questions and statements in repetitions

 

– Intraobserver for analyzers? Yes

  • Combined reliability for Perceptual Measures (Outcomes #1 through #6 which are listed below the reliability data) was high:

– Pre-treatment Intraclass Correlation Coefficient = 0.935

– Post-treatment Intraclass Correlation Coefficient = 0.799

OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences

OUTCOME #2: Improved intonation of questions and statements in reading and repetition

OUTCOME #3: Improved intonation of questions in reading and repetition

OUTCOME #4: Improved intonation of statements in reading and repetition

OUTCOME #5: Improved intonation of questions and statements in reading

OUTCOME #6: Improved intonation of questions and statements in repetitions

 

  • Reliability for Fo max which was used for Measures/ Outcomes #19 through #24 (they are listed below the reliability data ) was high:

– Pre-treatment Intraclass Correlation Coefficient = 0.998

– Post-treatment Intraclass Correlation Coefficient = 0.997

OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence reading task

OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of statements in a sentence repetition task

OUTCOME #19: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence reading task

OUTCOME #20: Improved median maximum fundamental frequency (Fo-max) of questions in a sentence repetition task

OUTCOME #21: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence reading task  

OUTCOME #22: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of statements in a sentence repetition task  

OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task  

OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task  

 

– Treatment fidelity for clinicians? Yes

  • Clinicians (C), 4 master’s graduate students in speech-language pathology, followed a treatment protocol.
  • The first author supervised the Cs.

 

 

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

 

SUMMARY OF IMPORTANT RESULTS

 

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

 

PRE AND POST TREATMENT ONLY ANALYSES

(only the Outcomes that achieved significance are listed)

 

PERCEPTUAL MEASURES:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences – postintervention was significantly higher than preintervention
  • OUTCOME #2: Improved intonation of questions and statements in reading and repetition–postintervention was significantly better than preintervention
  • OUTCOME #3: Improved intonation of questions in reading and repetition – postintervention was significantly better than preintervention
  • OUTCOME #5: Improved intonation of questions and statements in reading – postintervention was significantly better than preintervention

 

AUTOMATED MEASURES:

  • OUTCOME #16: Increased mean number of pauses in read passages – postintervention was significantly larger than preintervention

 

ACOUSTIC MEASURES:

  • OUTCOME #23: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence reading task – postintervention was significantly higher than preintervention
  • OUTCOME #24: Improved maximum fundamental frequency of the last syllable (Fo-max last syllable) of questions in a sentence repetition task – postintervention was significantly higher than preintervention

 

– What was the statistical test used to determine significance? Wilcoxon

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance

– What measure was used? Nonparametric Effect Size

 

– Results of EBP testing and the interpretation:

  • OUTCOME #1: Improved sentence intelligibility of read aloud nonsense sentences—nonparametric effect sixe = 0.83 (large effect)

 

 

  1. Were maintenance data reported? No

If yes, summarize findings:

 

  1. Were generalization data reported?  Yes
  • Since intelligibility was not the focus of the intervention, the outcome associated with intelligibility can be considered to be generalization.
  • The investigators reported that the post-intervention intelligibility was significantly higher than pre-invention intelligibility and that the effect size was large.

 

  1. Describe briefly the experimental design of the investigation.
  • In this single group, pre/post test investigation, 11 Ps from a volunteer group of 42 volunteers were selected using inclusion/exclusion criteria.
  • The Ps were all exposed to the same treatment administered by Cs who were master’s students in speech-language pathology. They were supervised by the first author.
  • The Ps were tested no more than 3 weeks before the intervention (pre) and no more than 3 days after treatment (post.)
  • The Cs administered the intervention over 3 weeks targeting speech rate and intonation.

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C+

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of an intensive intervention for PD using speech rate and intonation to improve intelligibility.

 

POPULATION: Parkinson’s disease, hypokinetic dysarthria

 

MODALITY TARGETED: expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: rate, intonation (terminal contour, overall)

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rate, intonation (terminal contour)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: intelligibility

 

DOSAGE: 5 one-hour individual sessions per week for 3 weeks

 

ADMINISTRATOR: master’s students in speech-language pathology

 

STIMULI: auditory, rhythmic gestures (hand tapping)

 

MAJOR COMPONENTS:

 

  • Intervention included the use of the Prosodietrainer, software developed for Dutch speakers with dysarthria. The Prosodietrainer records the Ps’ verbalizations, allows the P to replay his/her attempts, and provides visual feedback. However, the visual feedback monitor was not used in this investigation because it was in an experimental phase and because there was concern that Ps might be distracted by it.

 

  • During the initial sessions, the Cs explained that rate and intonation interventions were being implemented to improve intelligibility. The Cs did not directly target intelligibility during the intervention.

 

  • Intervention was intense—5 one-hour sessions per week for 3 weeks (15 sessions.)

 

  • Cs followed a protocol that specified

– intervention dosage

– content

– hierarchy of intervention steps

– feedback strategies

 

  • Major focus:

– reduce speaking rate (during the 1st half hour of a session)

– increase the contrast of the phrase final syllable of questions and statements (during the 2nd half hour of a session)

 

  • Rate reduction procedures:

– C instructed P to reduce rate by half.

– If the instruction was not successful, C used modeling or hand tapping to reduce rate.

– C did not instruct P to increase sound length or pause length.

 

  • Final syllable contrasts for statements versus questions:

– C directed P to

– produce questions with a rising terminal contour

– produce statements with a falling terminal contour

  • C provided feedback to P regarding the accuracy of attempts.

 

  • The intervention hierarchy involved increasing the linguistic complexity, length, and task complexity of the targets. The Prosodietrainer was programmed to individualize targets based on the Ps’ skill levels.

 

  • The Cs adhered to the principles of motor learning by providing clear brief instructions and models.

 

  • SPRINT therapy also involves massed practice.

 

  • Cs provided feedback regarding P performance and the functional accuracy of productions. As intervention progress, Cs gradually increased the rate and the delay time of feedback.

De Letter et al. (2007)

May 25, 2015

EBP THERAPY ANALYSIS

Treatment Groups

 

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

 

Key:

C = Clinician

EBP = evidence-based practice

NA = not applicable

P = Patient or Participant

PD = Parkinson’s disease

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE: De Letter, M., Santens, P., Estercam, I., Van Maele, G., De Bodt, M., Boon, P., & Van Borsel, J. (2007). Levodopa induced modifications of prosody and comprehensibility in advanced Parkinson’s disease as perceived by professional listeners. Clinical Linguistics and Phonetics, 21, 783-791.

REVIEWER(S): pmh

 

DATE: May 22, 2015

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

 

TAKE AWAY: This was not an intervention study; rather, it is classified as a clinically related investigation. Speakers of Dutch from Belgium with Parkinson’s disease (PD) were measured off (Pre-test) and on (Post Test) the medication Levodopa. Participants (Ps) produced significantly better pitch, loudness, and comprehensibility while using Levodopa. There was not a significant change in speaking rate on and off Levodopa conditions.

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Single Group with Pre- and Post-Testing
  • What was the level of support associated with the type of evidence? Level = C+

                                                                                                           

  1. Group membership determination:
  • Were participants 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 ß

                                                                    

 

  1. Was the group adequately described? Yes

How many participants were involved in the study?

  • total # of participant: 10
  • # of groups: 1
  • # of participants in each group: 10 participants (Ps) in the one group
  • List names of group: Ps with Parkinson’s disease (PD) were evaluated without (pretesting) and with (post testing) Levodopa.

 

The following variables were described:

  • age: 63 -80 years; mean 68 years
  • gender: 5m; 5f
  • cognitive skills: A psychiatrist administered a variety of tests and evaluated all Ps’ cognitive skills; none of the Ps were judged to be impaired.
  • therapy: None of the Ps were enrolled in speech therapy at the time of the investigation. No one was involved with deep brain stimulation and/or lesioning.
  • co-morbidity: No comorbidity was identified using neuroimaging and clinical judgment
  • medication: All Ps had been prescribed Levodopa previous to the investigation. Most of the Ps also were prescribed other medication(s) but none of the medication interfered with muscle movement.
  • diagnosis: advanced PD

 

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

                                                         

– Were the communication problems adequately described? No

  • disorder type: hypokinetic dysarthria

 

 

  1. Was membership in groups maintained throughout the study?
  • Did the group maintain at least 80% of their original members? Yes
  • Were data from outliers removed from the study? No

 

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

                                                                                                             

 

  1. Were the outcomes measure appropriate and meaningful?

– The outcomes (dependent variables) were

  • OUTCOME #1: Improved ratings of pitch on a 10 point scale from a read passage
  • OUTCOME #2: Improved ratings of loudness on a 10 point scale from a read passage
  • OUTCOME #3: Improved ratings of speaking rate on a 10 point scale from a read passage
  • OUTCOME #4: Improved ratings of comprehensibility on a 10 point scale from a read passage

All the outcome measures are subjective,

– None ofthe outcome measures are objective. None

                                         

 

  1. Were reliability measures provided?

– Interobserver for analyzers? Yes. Overall Interobserver reliability for all Ps and all outcomes was 0.78.

 

Intraobserver for analyzers?

 

–  Treatment fidelity for clinicians? No

 

 

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

PRE (without medications) VS POST (with Levadopa) TREATMENT:

  • OUTCOME #1: Improved ratings of pitch on a 10 point scale from a read passage: With Levodopa was significantly better (p < 0.01) than without Levodopa.
  • OUTCOME #2: Improved ratings of loudness on a 10 point scale from a read passage: With Levodopa was significantly better ( p < 0.01) than without Levodopa.
  • OUTCOME #3: Improved ratings of speaking rate on a 10 point scale from a read narrative No significant differences
  • OUTCOME #4: Improved ratings of comprehensibility on a 10 point scale from a read narrative With Levodopa was significantly better ( p = 0.01) than without Levodopa.

– What was the statistical test used to determine significance? Wilcoxon

 

– Were confidence interval (CI) provided? No

 

           

  1. What is the clinical significance? Not provided

 

  1. Were maintenance data reported? No

 

  1. Were generalization data reported? No

           

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C

 

 

SUMMARY OF INTERVENTION

 

 

PURPOSE: To investigate the effectiveness of the medication Levodopa on the perception of pitch, loudness, rate, and comprehensibility of read passages of Ps with PD.

POPULATION: PD; adults

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: pitch, loudness, rate

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: comprehensibility

 

DOSAGE: Single dosage of Levodopa.

 

ADMINISTRATOR: medical professional

 

MAJOR COMPONENTS:

  • In the pre condition, Ps had been off their medication for 12 hours. They reviewed a 182 syllable passage in Dutch prior to reading it aloud for audiorecording.
  • After the audiorecording, Ps were administered their regular dosage of Levodopa.
  • The Ps then waited one hour and re-read the same 182 syllable passage aloud for audiorecording.
  • Four speech-language pathologists (SLPs) listened to the audiorecodings. The audiorecordings for each of the Ps were randomized with respect to whether the sample was of the speaker with or without the Levodopa.
  • The SLPs rated each audiorecording for the following characteristics on a 10 point scale: pitch, loudness, rate, and comprehensibility.

Yorkston et al. (1990)

January 4, 2015

EBP THERAPY ANALYSIS

Comparison Learning Research

 

NOTE:  Scroll about 2/3s of the way down the page to view a description of the 4 rate control strategies and procedures.

KEY:

C = clinician(s)

P = participant(s)

pmh = Patricia Hargrove, blog developer

wpm = words per minute

 

SOURCE: Yorkston, K. M., Hammen, V. L., Beukelman, D. R., & Traynor, C. D. (1990). The effect of rate control on the intelligibility and naturalness of dysarthric speech. Journal of Speech and Hearing Disorders, 55, 550-560.

 REVIEWER(S): pmh

DATE: January 3, 2015

 

ASSIGNED GRADE FOR OVERALL QUALITY: C- (The highest possible grade for this design was B+.)

 

TAKE AWAY: This investigation is concerned with learning and should not be considered evidence of the effectiveness of an intervention. Nevertheless, learning research can provide guidance to clinicians (C). The findings from this investigation indicated that slowing the rate of speech can result in improvements in the speech of participants (Ps) with ataxic or hypokinetic dysarthria. Metered strategies are more likely to improve sentence intelligibility, although one type (Additive Rhythmic) of rhythmic rate control strategy also results in sentence intelligibility improvement. On the other hand, metered strategies tend to be associated with the more severe degrading of ratings of speech naturalness than the rhythmic approaches.

 

 

  1. What type of evidence was identified?
  • What was the type of evidence? Comparison Research–Prospective, Nonrandomized Group Design with Controls
  • What was the focus of the research? Clinically Related
  • What was the level of support associated with the type of evidence? Level = B+

                                                                                                           

  1. Group membership determination:
  • If there were groups, were participants randomly assigned to groups? No
  • If the Ps were not randomly assigned to groups, were members of groups carefully matched? Yes

                                                                    

    3.  Were experimental conditions concealed?

  • from participants? No
  • from administrators of experimental conditions? No
  • from analyzers/judges? Yes

                                                                   

  1. Were the groups adequately described? Yes

 How many participants were involved in the study?

  • total # of participant:  12
  • # of groups:  3
  • # of participants in each group: 4
  • List names of groups: Ataxic (A) Group, Hypokinetic (H) Group, Typical Speaking (TS) Group
  • Did all groups maintain membership? No. Only partial data are reported for 1 P from the A group due to a change in her medical status.

  The following variables were described or controlled:

  • age: 30-70 years
  • gender: 4f, 8m
  • first language: English
  • expressive language:
  • years post onset: 3-29 years
  • etiology:

     – A group = cerebellar degeneration, traumatic brain injury (2), tumor resection

     – H group = Parkinson’s disease (3), cerebral palsy with dystonic posturing

     – TS group = all Ps had no history of neurologic disorder:

  •  Were the groups similar before intervention began? Not Applicable
  •   Were the communication problems adequately described? Unclear
  • disorder type:

     – TS group – no reported speech disorder

– A group — pure ataxic (2), ataxic/spastic (1), ataxic/flaccid (1)

– H group – all hypokinetic

 

  1. What were the different conditions for this research?

Subject (Classification) Groups?

– A group

– H group

– TS group                                                               

Experimental Conditions?

  • rate of speech (habitual, 80% of habitual, 60% of habitual)
  • rate control strategies

– Additive Metered (AM

– Additive Rhythmic (AR)

– Cued Metered (CM)

– Cued Rhythmic (CR)

 

  1. Were the groups controlled acceptably? Yes

  

  1. Were dependent measures appropriate and meaningful? Yes                                                                                                      

The dependent measures

  • Measure #1: Speaking rate in words per minute (wpm)
  • Measure #2: Sentence intelligibility
  • Measure #3: Phoneme intelligibility
  • Measure #4: Speech naturalness

The dependent measures that are subjective are

  • Measure #2: Sentence intelligibility
  • Measure #3: Phoneme intelligibility
  • Measure #4: Speech naturalness

The dependent/ outcome measures that are objective are

  • Measure #1: Speaking rate in words per minute (wpm)

                                       

  1. Were reliability measures provided? Yes, some.

Interobserver for analyzers? Yes

  • Measure #3: Phoneme intelligibility—The investigators cited previous research reporting this information. Because they used a short version of the previously researched measure, the investigators also reported the average range of judges scores:

– Overall average range = 8.9%

– Average range for consonants = 9.6%

– Average range for vowels = 17.9%

 

  • Measure #4: Speech naturalness—The average standard deviation among the 9 judges was 0.97 points on the rating scale.

 

Intraobserver for analyzers?   Yes

  • Measure #4: Speech naturalness:

– A group = 88%

– H group = 91%

– I group = 89%

 

Treatment fidelity for investigators? Yes, kind of. However, the investigators described the accuracy of the rate control conditions. That is, they determined if Ps really spoke at 60% and 80% of their habitual rates during the slowed conditions by calculating or computing the rate of speech in each of the rate conditions and rate control strategies. Overall, the investigators determined that the computer software accurately paced the Ps rate of speech.

  

  1. Description of design:
  • The investigators compared the performance of A, H, and TS group during habitual speaking rate and during 2 slowed conditions (80% and 60% of habitual rate.)
  • The rates were slowed via computer pacing using 4 different strategies:

– Additive Metered (AM)

– Additive Rhythmic (AR)

– Cued Metered (CM)

– Cued Rhythmic (CR)

  • The dependent variables/outcome measures were sentence intelligibility, phoneme intelligibility, and speech naturalness.

 

  1. What were the results of the statistical (inferential) testing?—There was no inferential testing, only descriptive statistics.
  • Measure #1: Speaking rate in words per minute (wpm) — The investigators judged that the speaking rates were accurately paced. That is, the targets of 80% and 60% of habitual speech generally were accurately produced by the Ps.
  • Measure #2: Sentence intelligibility

     – The effect of rate control on the 2 clinical (A, H) groups: The investigators judged that as speakers reduced their speaking rate, sentence intelligibility improved using measures of mean sentence intelligibility and the charting of individual performances.

– The effectiveness of each of the 4 rate control strategies was investigated for the 2 clinical groups using the data associated with the 60% rate. The investigators determined that the 2 metered strategies (AM, CM) consistently resulted in higher scores than the rhythmic (AR, CR) strategies.

– Individual rankings of the 4 rate control strategies revealed that CM was most often the most effective strategy and CR was the least effective strategy.

– My (pmh) review of the data indicated that although one of the rhythmic strategies (AR) also resulted in marked improvements of sentence intelligibility.

  • Measure #3: Phoneme intelligibility

– The investigators reported that that phoneme intelligibility did not appear to vary (improve or decrease) as the clinical Ps’ (i.e., A and H groups) speaking rate decreased.

– Inspection of the data of individual clinical Ps revealed inconsistent responses to slowed rate: some Ps improved, some Ps regressed.

– Vowel intelligibility seemed to be particularly challenging for the clinical Ps. One common trend was observed in the A group: at slowed rates, judges tended to perceive single vowels as diphthongs.

  • Measure #4: Speech naturalness

– The investigators compared the 2 clinical groups (A and H) and the TS group.

– Overall (all Ps, rates, and rate control strategies) the lowest naturalness judgments were associated with the A group. The H group’s naturalness scores were in the middle and the best naturalness ratings were for the TS group.

– The largest decrease in naturalness ratings was for the TS group when comparing the habitual and the 60% of habitual rate.

– Although the A and H groups’ trends indicated that there were decreases in naturalness rating associated with the slowed rate, the changes were minimal.

– The investigators also explored the effectiveness of the different rate control strategies on speech naturalness. For this comparison, however, they combined the data from the metered (AM, CM) and the rhythmic (AR, CR) strategies.

– For all 3 groups of Ps, the metered strategies resulted in the poorest naturalness scores. The largest decrease in naturalness scores occurred in the TS group.

 

  1. Brief summary of clinically relevant results:
  • Slowed rate of speech resulted in improved sentence (but not phoneme) intelligibility in A and H speakers.
  • The most effective rate control strategies were metered strategies (AM, CM) although, the additive rhythmic strategy seemed pretty close to the metered strategies.
  • Metered rate control strategies were consistently poorer than rhythmic rate control strategies and the habitual rate.

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: ___C-__

 

 

 

SUMMARY OF PROCEDURES

 

PURPOSE: to investigate the effect of slowed rate and four rate control strategies on sentence intelligibility, phoneme intelligibility, and speech naturalness.

POPULATION: Ataxic dysarthria, Hypokinetic dysarthria (Parkinson’s disease, PD), and typical speakers (TS)

 

MODALITY TARGETED: expression

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: rate

 

ELEMENTS OF PROSODY USED AS INDEPENDENT VARIABLE: rate, rhythm

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: sentence intelligibility, phoneme intelligibility, and speech naturalness

DOSAGE: 3 two-hour sessions (this was not an intervention; it was a learning experiment.)

 

GENERAL PROCEDURE:

 

  • There were 4 rate control strategies:

– Additive Metered (AM): The C presented the words in a targeted sentence one word at a time on a computer screen at the predetermined speaking rate. Each word was presented on the screen for the same amount of time. (C had previously shared the sentences with C so as to familiarize him/her with the sentences.)

– Additive Rhythmic (AR): The C presented the words in a targeted passage using timing one would produce in typical speech. Each word was presented on the screen for the amount of time a typical speaker would produce the word. (C had previously shared the sentences with C so as to familiarize him/her with the sentences.)

– Cued Metered (CM): C presented the entire target passage to the P on a computer screen. C cued the words at the predetermined rate by underlining each targeted word. Each word was underlined for the same amount of time

– Cued Rhythmic (CR): C presented the entire target passage on a computer screen to the P. C cued the words at the predetermined rate by underlining each targeted word. Each word was presented on the screen for the amount of time a typical speaker would produce the word.

  • The investigators identified each P’s habitual rate of speaking using a set of read stimuli. They then had Ps read other similar stimuli at slowed rates of speech (60% and 80% of the habitual rate) using the 4different rate control strategies.