Kim & Tomaino (2008)

January 29, 2018

EBP THERAPY ANALYSIS

Treatment Groups 

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

 Key:

C = Clinician

EBP = evidence-based practice

f = female

m = male

MT = music therapy

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

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

 

REVIEWER(S): pmh

 

DATE: January 26, 2018

 

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

 

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

 

 

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

                                                                                                          

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

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

 

 

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

                                                                    

 

  1. Were the Ps adequately described? Yes

How many Ps were involved in the study?

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

 

– CONTROLLED CHARACTERISTICS

  • Diagnosis: Nonfluent Aphasia

 

– DESCRIBED CHARACTERISTICS

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

 

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

                                                         

– Were the communication problems adequately described? Yes

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

∞ 3 Ps were diagnosed with apraxia

∞ 1 P was diagnosed with dysarthria

∞ 2 Ps were diagnosed with dysphagia

∞ 2 Ps were diagnosed with fluent aphasia

∞ 1 P was diagnosed with receptive aphasia

 

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

 

 

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

                                                               

  • Were data from outliers removed from the study? No

 

 

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

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

– OUTCOMES

  • OUTCOME #1: Articulation skills (accuracy rating)

 

  • OUTCOME #2: Fluency (words per utterance)

 

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

 

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

 

ALL the outcome measures were subjective.

 

– NONE of the outcome measures that were objective.

                                         

 

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

 

  • Intraobserver for analyzers?   No

 

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

 

 

  1. Summary of the description of the results:

 

PRE AND POST TREATMENT ANALYSES

 

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

 

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

 

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

 

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

 

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

 

– Were confidence interval (CI) provided? No

 

 

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

 

 

  1. Were maintenance data reported? No

 

 

  1. Were generalization data reported? No

 

 

  1. Describe briefly the experimental design of the investigation.

 

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

 

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

 

  • The 7 MT techniques were

– Singing Familiar Songs

– Breathing into Single Syllable Sounds

– Dynamically Cued Singing

– Musically Assisted Speech

– Rhythmic Speech Cuing

– Oral Motor Exercise

– Vocal Intonation

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C-

 

 

SUMMARY OF INTERVENTION

 

 

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

 

POPULATION: Nonfluent Aphasia; Adults

 

MODALITY TARGETED: Production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: rhythm, intonation

 

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

 

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

 

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

 

ADMINISTRATOR: Music therapist.

 

MAJOR COMPONENTS:

 

 

 

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

 

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

– Singing Familiar Songs

– Breathing into Single Syllable Sounds

– Dynamically Cued Singing

– Musically Assisted Speech

– Rhythmic Speech Cuing

– Oral Motor Exercise

– Vocal Intonation

 

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

 

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

 

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

 

SINGING FAMILIAR SONGS

 

  • Description:

– C leads P in the singing of familiar songs.

– C directs P to select a favorite song.

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

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

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

 

  • Evidence: (see also Item #9 above)

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

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

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

EXAMPLE: P1

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

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

EXAMPLE: P5

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

 

  • Hints:      

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

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

It is better to use songs that P knew premorbidly.

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

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

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

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

 

 

BREATHING INTO SINGLE SYLLABLE SOUNDS

 

 

  • Description:

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

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

 

  • Evidence: (see also Item #9 above)

– Articulatory accuracy increased when Cs introduced pauses between syllables.

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

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

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

 

  • Hints:

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

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

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

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

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

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

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

 

 

DYNAMICALLY CUED SINGING

 

 

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

 

  • Evidence: (see also Item #9 above)

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

– This technique seemed effective in encouraging attention as indicated by

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

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

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

 

  • Hints:

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

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

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

 

 

MUSICALLY ASSISTED SPEECH

 

 

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

 

  • Evidence: (see also Item #9 above)

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

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

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

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

 

  • Hints:

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

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

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

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

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

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

 

 

RHYTHMIC SPEECH CUING

 

 

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

 

  • Evidence: (see also Item #9 above)

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

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

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

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

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

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

 

  • Hints:

– Cues include:

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

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

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

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

 

 

ORAL MOTOR EXERCISE

 

 

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

 

  • Evidence: (see also Item #9 above)

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

 

  • Hints:

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

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

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

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

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

 

 

VOCAL INTONATION

 

 

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

 

  • Evidence: (see also Item #9 above)

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

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

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

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

 

  • Hints:

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

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

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

 

Advertisements

Poore & Ferguson (2008)

November 5, 2016

ANALYSIS GUIDELINES

Comparison Research

 

NOTE: No summary of intervention is included in the review because the investigation does not involve therapy.

 KEY:

 eta =   partial eta squared

f = female

fo = Fundamental frequency

m = male

MLU = mean length of utterance

NA = Not Applicable

P = participant or patient

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

 

 

SOURCE: Poore, M. A., & Ferguson, S. H. (2008.) Methodological variables in choral reading. Clinical Linguistics & Phonetics, 22 (1), 13-24.

 

REVIEWER(S): pmh

 

DATE: November 4, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: Not graded because this was not an intervention study; nevertheless, it does have clinical implications.

 

TAKE AWAY: The investigators explored prosody of typical adults in a variety of reading contexts (3 scripts and 3 reading conditions.) Compared to Solo reading, Choral reading resulted in smaller fundamental frequency (fo) variability, smaller amplitude variability, and smaller vowel duration variability. Track reading (i.e., in unison with prerecorded scripts) resulted in significantly more vowel errors, suggesting that Track reading might not be a feasible alternative to Choral reading.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of design? Prospective Single Group Experiment (exposed to Mmultiple conditions)

 

  • What was the focus of the research? Clinically Related

           

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there were 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? Unclear

                                                                    

 

  1. Were the groups adequately described? Yes

 

–   How many participants were involved in the study?

 

  • total # of Ps:  22 Ps (11 pairs) were in the original group. See question about maintenance below for description of loss of participants (Ps.)
  • # of groups: 1
  • Did the group maintain membership throughout the investigation? No, 6 of the pairs (i.e., 12 Ps) were eliminated from the investigation due to recording and/or interference issues at the time of the recording. Therefore, there were only 5 pairs of Ps resulting in 10 Ps.

 

DESCRIBED OR CONTROLLED CHARACTERISTICS                 

  • age:

     – original group: 18 to 25 years

– final group: not reported

  • gender:

     – original group: 8m; 14f

– final group: 4m; 6f:

  • dialect: South Midland Dialect of American English
  • communication skills: No history of speech, language, or hearing disorders; investigator judged speech to be typical

 

Were the groups similar? NA

                                                         

– Were the communication problems adequately described? Yes

  • disorder type: NA, communication skills of all Ps were within normal limits

 

 

  1. What were the different conditions for this research?

                                                                                                             

  • Subject (Classification) Groups?

                                                               

  • Experimental Conditions? Yes

– type of reading material: poetry, fiction, textbook

– reading condition: solo, track, choral

 

  • Criterion/Descriptive Conditions? No

 

 

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

 

 

  1. Were dependent measures appropriate and meaningful? Yes

 

The dependent measures were

 

  • OUTCOME #1: Fundamental frequency (fo) variability
  • OUTCOME #2: Amplitude variability
  • OUTCOME #3: Vowel duration
  • OUTCOME #4: Number of vowel errors

 

– Outcome #4 (Number of vowel errors) was subjective.

 

Three of the outcomes (see below) were objective:

  • OUTCOME #1: Fundamental frequency (fo) variability
  • OUTCOME #2: Amplitude variability
  • OUTCOME #3: Vowel duration

 

 

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? No

 

– Intraobserver for analyzers? Yes

 

  • OUTCOME #3: Vowel duration- Because the measurement of vowel duration required judgment on the part of the analyzers, the investigators provided intraobserver reliability data. The correlation for remeasured vowels was 0.95

 

– Treatment or test administration fidelity for investigators? No

 

 

  1. Description of design:

 

  • Although 22 Ps (11 pairs) initially participated in the investigation, only the data from 10 Ps were analyzed due to technical issues with the recordings.

 

  • All reading were recorded.

 

  • Pairs of Ps elicited the samples by reading scripts in the following order:

– Each speaker in the pair was directed to read silently the 3 scripts (poetry, nonfiction, textbook.) The order of the scripts was counterbalanced.

– First: Solo reading of all designated scripts alone. While separated from his/her experimental partner, each P read his/her scripts alone.

– Second and Third: The order of Track and Choral readings were counterbalanced.

  • TRACK READINIG: Using his/her partner’s Solo reading script as stimuli, P read aloud his/her scripts in unison with the recorded readings of his/her experimental partner.
  • CHORAL READINIG: P read aloud his scripts in unison with the live reading of the same scripts with his/her experimental partner.

 

  • Some data were removed from the investigation:

– Potential outliers were identified for fo variability by highlighting

  • fo more than 2 standard deviations (SD) from the mean

     – The potential outliers were then inspected. If a fo was not continuous with the upper and/or lower limits of the P’s range, it was removed.

 

 

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

 

– Comparisons that were significant (e.g., p ≤ 0.05):

 

  • OUTCOME #1: Fundamental frequency (fo) variability

– fo was significantly more variable in the solo condition

– script type, gender, gender pair, interactions were not associated with significant fo variability

 

  • OUTCOME #2: Amplitude variability

– Amplitude variability was significantly smaller for choral reading compared to solo and track reading

– script type and interactions were not associated with significant amplitude variability

 

  • OUTCOME #3: Vowel duration variability

– Differences among the 3 reading conditions were significantly different

– order of variability from most to least: track, solo, choral

 

  • OUTCOME #4: Number of vowel errors

     – The track condition was associated with significantly more errors than the other 2 conditions.

 

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

 

– Were effect sizes provided? Yes, for some, but not all, comparisons..

 

  • OUTCOME #1: Fundamental frequency (fo) variability;

– Solo condition most variable; eta = 0.83 (strong)

 

  • OUTCOME #2: Amplitude variability

– Amplitude variability least variable in choral reading; eta = 0.73 (strong)

 

  • OUTCOME #3: Vowel duration variability

– Order of variability from most to least: track, solo, choral; eta = 0. 69 (strong)

 

– Were confidence interval (CI) provided? No

 

 

  1. Summary of correlational results:  NA

 

 

  1. Summary of descriptive results: Qualitative research NA (this item is completed only when the investigation was solely or primarily Qualitative in nature.)

 

 

  1. Brief summary of clinically relevant results:

 

  • The fo variability, amplitude variability, vowel duration variability, and vowel errors did not differ in the 3 types of script (poetry, nonfiction, textbook.) The investigators suggested this could be associated with the small N.

 

  • Choral reading appeared to be associated with

– smaller fo variability

– smaller amplitude variability

– smaller vowel duration variability

 

  • Track reading often differed from the other conditions in fo variability and vowel duration variability. Moreover, significantly more errors were noted in the track condition.

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: NA


de Azevedo et al. (2015)

February 1, 2016

EBP THERAPY ANALYSIS

Treatment Groups

 

 

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

 

Key:

C = Clinician

EBP = evidence-based practice

f = female

F0 = fundamental frequency

LVST = Lee Silverman Voice Treatment

LVST-a = Lee Silverman Voice Treatment-adapted

m = male

NA = not applicable

P = Patient or Participant

PT = prominent tonic

PD = Parkinson’s disease

SLP = speech–language pathologist

UPT = unstressed pre-tonic

 

 

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

 

REVIEWER(S):  pmh

 

DATE: January 30, 2016

 

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

 

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

 

 

  1. What type of evidence was identified?

                                                                                                           

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

 

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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

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

 

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

                                                                    

 

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

 

– How many Ps were involved in the study? 10

 

– total # of Ps: 10

 

– # of groups: 1

 

– The P characteristics that were CONTROLLED were i.

 

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

 

– The P characteristics that were DESCRIBED were

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

 

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

                                                         

– Were the communication problems adequately described? No

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

 

 

  1. Was membership in the group maintained throughout the study?

                                                                                                             

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

                                                               

  • Were data from outliers removed from the study? No

 

 

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

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

The outcomes were

 

FUNDAMENTAL FREQUENCY (F0) OUTCOMES

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

 

DURATION OUTCOMES

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

 

INTENSITY OUTCOMES

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

 

NONE of the outcome measures were subjective.

 

ALL of the outcome measures were objective.

 

                                         

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

 

 

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

 

  • Summary Of Important Results

 

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

 

 

PRE AND POST TREATMENT ONLY ANALYSES

 

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

 

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

 

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

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

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

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

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

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

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

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

 

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

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

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

OUTCOME #16: PT duration (significantly shorter posttest)

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

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

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

 

 

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

 

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

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

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

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

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

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

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

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

 

 

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

 

  • Were confidence interval (CI) provided? No

 

 

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

 

 

  1. Were maintenance data reported? No

 

 

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

 

 

  1. Describe briefly the experimental design of the investigation.

 

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

 

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

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

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

 

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

 

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

 

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

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

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

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

 

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

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C+

 

 

SUMMARY OF INTERVENTION

 

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

 

POPULATION: Parkinson’s disease

 

MODALITY TARGETED: production

 

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

 

ELEMENTS OF PROSODY USED AS INTERVENTION: Loudness

 

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

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

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

 


Ramig et al. (2001b)

September 5, 2014

EBP THERAPY ANALYSIS

Treatment Groups

 

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

 

Key:

C = Clinician

EBP = evidence-based practice

f = female

LSVT = Lee Silverman Voice Treatment

m = male

NA = not applicable

P = Patient or Participant

PD = Parkinson’s disease

pmh = Patricia Hargrove (blog developer)

RET = respiratory therapy

UPDRS = Unified Parkinson’s Disease Rating Scale

SLP = speech–language pathologist

SPL = sound pressure level, a measure of loudness

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

 

 

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

 

REVIEWER(S): pmh

 

DATE: September 5, 2014

 

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

 

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

 

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

                                                                                                           

 

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

 

 

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

                                                                    

 

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

                                                                                

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

 

The following characteristics were described:

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

 

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

                                                         

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

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

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

 

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

 

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

 

  1. None of the outcome measures are subjective.

                                         

 

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

 

  1. Intraobserver for analyzers? No

 

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

 

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

 

TREATMENT GROUP VERSUS COMPARISON TREATMENT GROUP

 

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

 

 

PRE VS POST TREATMENT (only significant changes are noted)

 

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

–LSVT: significant improvement from pre to post

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

 

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

–LSVT: significant improvement from pre to post

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

–RET: significant improvement from pre to post

 

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

–LSVT: significant improvement from pre to post

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

 

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

–LSVT: significant improvement from pre to post

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

–RET: significant improvement from pre to post

 

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

–LSVT: significant improvement from pre to post

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

 

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

 

  1. Were confidence interval (CI) provided? No

 

                                               

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

 

 

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

 

  1. Were generalization data reported? No

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: B+

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of LSVT

 

POPULATION: Parkinson’s disease

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: loudness, intonation

 

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

 

OTHER TARGETS:

 

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

 

ADMINISTRATOR: 2 SLPs

 

STIMULI: auditory stimuli, visual feedback

 

MAJOR COMPONENTS:

 

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

– focused on high and maximum effort

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

– assigned daily homework

 

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

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

 

RET

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

 

 


McMicken et al (2011)

August 16, 2014

Single Subject Designs

 

Notes:

 

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

 

  1. Key:

C = clinician

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

LSVT = Lee Silverman Voice Treatment

NA = not applicable

P = participant or patient

pmh = Patricia Hargrove, blog developer

RFP = Ryan Fluency Program

WNL = within normal limits

 

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

 

REVIEWER(S): pmh

 

DATE: August 16, 2014

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

 

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

 

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

                                                                                                           

 

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

                                                                                                           

 

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

 

 

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

 

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

                                                                                                             

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

                                                                                                                       

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

 

 

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

 

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

OUTCOME #1: To increase the duration of vowel prolongations

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

OUTCOME #3: To improve (decrease) severity ratings

OUTCOME #4: To improve (increase) intelligibility ratings

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

  1. The outcomes that were subjective are

OUTCOME #3: To improve (decrease) severity ratings

OUTCOME #4: To improve (increase) intelligibility ratings

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

  1. The outcomes that were objective are

OUTCOME #1: To increase the duration of vowel prolongations

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

                                                                                                             

  1. The outcome measures with reliability data are

OUTCOME #3: To improve (decrease) severity ratings

OUTCOME #4: To improve (increase) intelligibility ratings

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

 

 

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

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

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

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

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

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

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

 

 

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

 

 

  1. Was information about treatment fidelity adequate? Not Provided

 

 

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

 

 

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

 

 

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

 

 

SUMMARY OF INTERVENTION

 

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

POPULATION: Ataxic Dysarthria; Adult

 

MODALITY TARGETED: expression

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rate, loudness

 

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

 

OTHER TARGETS: self-perception of communication skills

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

 

ADMINISTRATOR: SLP

 

MAJOR COMPONENTS:

 

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

LSVT:

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

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

– C uses the following forms of feedback/reinforcement

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

GILCU of RFP:

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

  1. conversation
  2. reading
  3. monologue

 

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

ESTABLISHMENT

– C presents targets in a specified order:

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

TRANSFER

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

MAINTENANCE

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

Maas & Farinella (2012)

August 12, 2014

Single Subject Designs

 

Notes:

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

2. Key:

C = clinician

CAS = childhood apraxia of speech

CNT = could not test

DTTC = Dynamic Temporal and Tactile Cueing

ES = effect size

NA = not applicable

P = participant or patient

S = strong syllable

SLP = speech=language pathologist

w = weak syllable

WNL = within normal limits

 

SOURCE: Maas, E., & Farinella, K. A. (2012). Random versus blocked practice in treatment for childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 55, 561-578.

 

REVIEWER(S): pmh

 

DATE: August 8, 2014

ASSIGNED OVERALL GRADE: B+

 

TAKE AWAY: The focus of these single subject experimental design investigations was to determine if there was an advantage for blocked versus random practice for children with childhood apraxia of speech (CAS). The investigation is relevant to this blog because the intervention involved the manipulation of rate. The investigators included a thorough description of the participants (Ps), intervention, and scoring of P responses to treatment conventions. The intervention was judged to be effective for 3 of the 4 Ps but the results regarding the practice schedule were equivocal.

                                                                                                           

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

                                                                                                           

 

  1. What type of evidence was identified?

a. What type of single subject design was used? Single Subject Experimental Design with Specific Clients- Alternating Treatments Design with Multiple Baselines across Behaviors

                                                                                                           

b. What was the level of support associated with the type of evidence?

Level = A                                                         

 

                                                                                                           

  1. Was phase of treatment concealed?

a. from participants? No

b. from clinicians? No

c. from data analyzers? Yes

 

 

  1. Were the participants adequately described? Yes

a. How many participants were involved in the study? List here: 4

 

b. The following characteristics were described:

  • age: 5;0 to 7;9
  • gender: 2m; 2f
  • expressive language: moderate delay (2); severe delay (1); could not test (CNT, 1)
  • receptive language: within normal limits (WNL, 2); low- average (1); mild-moderate delay (1)
  • language spoken: all monolingual English speakers
  • Hearing: all WNL
  • Medical/neurological diagnosis: none had diagnoses at the time of the investigation
  • motor skills: limited manual motor skills (1); history of hypotonia and gross/fine motor delay (1)
  • sensory processing skills: impaired (1)

                                                 

c. Were the communication problems adequately described? Yes

  • The disorder type was CAS
  • Other aspects of communication that were described for each of the Ps:

P1

  • inconsistent vowel/consonant substitutions/distortions
  • segmented speech
  • intermittent hypernasality
  • equal and incorrect stress in multisyllabic words
  • reduced intelligibility
  • inconsistent phonological patterns

P2

  • inconsistent vowel/consonant errors
  • articulatory groping
  • intermittent hypernasality
  • breathy/harsh voice quality
  • stereotypical nonword utterance
  • mild left facial asymmetry
  • possible mild unilateral upper motor neuron dysarthria

P3

  • moderate-severe dysarthria (mixed spastic-flaccid)
  • inconsistent consonants/vowels errors
  • speech sound and syllable segmentation
  • intermittent hypernasality
  • intermittent hoarse/breathy voice quality
  • weakness of the tongue
  • prosodic abnormalities (incorrect and equal stress, reduced speech rate)

P4

  • prosodic abnormalities (incorrect and excessive stress, segmentation of syllables)
  • occasional speech sound distortions and vowel errors were occasionally observed

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Yes

a. If there was more than one participant, did at least 80% of the participants remain in the study? Yes

b. Were any data removed from the study? No

 

 

  1. Did the design include appropriate controls? Yes

a. Were baseline collected on all behaviors? Yes

b. Did probes include untrained data? Yes

c. Did probes include trained data? Yes

d. Was the data collection continuous? No

e. Were different treatment counterbalanced or randomized? Yes

  1. f. Was treatment counterbalanced or randomized? Randomized?

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

a. The outcome:

OUTCOME #1*: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probes

* The investigators designed separate word lists for each P, taking into consideration speech sound error profiles. The following were the targets:

– initial cluster

– 2 syllable words

– 3 syllable words

– final clusters

– final fricative

– final liquids

– initial fricatives

– initial liquids

– 4 syllable Strong-Weak-Strong-Weak (SwSw) words

– 4 syllable wSwS words

– 3 syllable wSw words

– 3 syllable Sww words

b. The outcome was subjective.

c. The outcomes was not objective.                                            

d. The investigators provided outcome reliability data.

e.  The mean interrater reliability ranged from 79% to 87%.

 

  1. Results:
  2. Did the target behavior improve when it was treated? Inconsistent
  3. b.   For

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probes —The overall quality of improvement was moderate

– P1, P3, P4 –improved **

– P2 did not improve

(**NOTE–The findings regarding the relative effectiveness of the practice schedule were equivocal; 2Ps exhibited stronger progress for the blocked schedule and 1P exhibited stronger progress with the random schedule.)

  1. Description of baseline:
  2. Were baseline data provided? Yes

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probes – 3 data points

 

  1. Was baseline low and stable? (The numbers should match the numbers in item 7a.)

OUTCOME #1: For the most part, baseline was low (the highest percentage correct of a target during baseline was approximately 35%) and moderately stable.

                                                                                       

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

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probe

  • P1 – PND was 75% to 100% (fairly to highly effective)
  • P2 – PND was 0% for all targets (ineffective)
  • P3 – PND was 0% to 75% (ineffective to fairly effective)
  • P4 – PND was 0% to 50% (ineffective to questionable effectiveness)

 

 

  1. What was the magnitude of the treatment effect.”

 

NOTE: The investigators used an effect size (ES) of 1.00 or more as evidence of effectiveness (p. 567); there was no gradation for effectiveness.

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probe

  • P1 – ES was 3.55 (random) and 4.04 (block)
  • P2 – ES was 0.62 (blocked); random could not be calculated because of zero variance.
  • P3 – ES was 3.16 (random) and 1.50 (block)
  • P4 – ES was 1.31 (random) and 1.69 (block)

 

  1. Was information about treatment fidelity adequate? Yes. Treatment fidelity ranged from 61% to 88%. One P was associated with percentages ranging from 61% to 71%. All other Ps had percentages of 75% or above.

 

 

  1. Were maintenance data reported? Yes. There were multiple specific targets for each of the Ps. Although there were some exceptions, for the most part, Ps did not maintain their gains in therapy at a follow-up session one month after termination of the investigation.

 

 

  1. Were generalization data reported? Yes Generalization varied; overall should be described as limited.

 

 

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

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To improve motor speech learning

POPULATION: Childhood Apraxia of Speech; Child

 

MODALITY TARGETED: expression

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rate

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: speech sounds

DOSAGE: 3 times a week,

 

ADMINISTRATOR: SLP or a graduate clinician

 

STIMULI: visual stimuli (index cards—10 of each target), auditory stimuli, tactile cues

 

MAJOR COMPONENTS:

  • The investigators use Dynamic Temporal and Tactile Cueing (DTTC) as a treatment but they compared using random and blocked practice schedules for their investigation.
  • DTTC includes motor learning, modeling, integral stimulation, drill, focus on core vocabulary, rate reduction, variation in gap between C’s model and P’s attempt, tactile cues, reinforcement, and variation in feedback schedule.
  • Blocked Practice = index cards for the same word were practiced together and then C moved on to the next word
  • Random Practice = C shuffled the all the cards that were to be used for that day’s session

 

  • C provided verbal feedback to P only 60% of the time
  • Steps in DCCT

1. C directs P “Watch me, listen carefully, and repeat after me” (p. 577). C then produces the target word on the index card.

2. When P is correct, C waits 2 to 3 seconds, and either

– provides feedback (60% of the time) and reinforces C tangibly (e.g., stickers or bubbles) and

– goes to the next word.

3. When P is incorrect,

– during feedback trials (60% of the time)

  • C waits 2- 3 seconds
  • C notes that the production was not accurate and describes how it was inaccurate
  • up to 2 times, C and P slowly and simultaneously produce the target word
  • C then fades support by only mouthing the target word during an attempt to produce it
  • C produces the word and P immediately imitates it
  • C waits 2 to 3 seconds before providing feedback

– during No Feedback trials (40% of the time)

  • C waits 2- 3 seconds
  • up to 2 times, C and P slowly and simultaneously produce the target word
  • C then fades support by only mouthing the target word during an attempt to produce it
  • C produces the word and P immediately imitates it
  • C waits 2 to 3 seconds and then says “Now let’s do another one” (p. 577).

Jalled et al. (2000)

July 31, 2014

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

 

NOTE: The summary of the intervention procedures can be viewed by scrolling about two-thirds of the way down this page.

 

KEY:

AMRT = Arabic Melodic and Rhythmic Therapy, an Arabic adaptation of Melodic and Rhythmic Therapy

C = clinician

MIT = Melodic Intonation Therapy

MRT = Melodic and Rhythmic Therapy, a French adaptation of MIT

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist or equivalent

 

Source: Jalled, F., Skik, H., & Mrabet, A. (2000). Arabic melodic and rhythmic therapy: A method of severe aphasia therapy. Neurosciences, 5 (2), 91- 93.

 

Reviewer(s):  pmh

 

Date: July 31, 2014

 

Level of Evidence: F = Expert Opinion, no supporting evidence for the effectiveness of the intervention although the author may provide secondary evidence supporting components of the intervention.

 

Take Away: The authors describe a Tunisian Arabic adaptation (AMRT) of Melodic and Rhythmic Therapy (MRT) which is a French adaptation of Melodic Intonation Therapy (MIT). The authors provided the linguistic basis of the modifications, procedures for the AMRT, and a summary of some research supporting AMRT.

 

  1. Was there review of the literature supporting components of the intervention? Narrative Review

 

  1. Were the specific procedures/components of the intervention tied to the reviewed literature? No

 

  1. Was the intervention based on clinically sound clinical procedures? Yes

 

  1. Did the author(s) provide a rationale for components of the intervention? Yes

 

  1. Description of outcome measures:

List the outcome measure(s). List (add additional numbers if necessary):

  • Outcome: To speak using natural prosody while producing spontaneous utterances.

 

  1. Was generalization addressed? Yes

 

  1. Was maintenance addressed? No

 

 

SUMMARY OF INTERVENTION

 

Description of Intervention —Arabic Melodic and Rhythmic Therapy (ARMT)

 

POPULATION: Aphasia; Adults

— The authors recommended that the following characteristics are associated with good progress:

  • site of lesion- anterior portion of the left hemisphere;
  • reduced expressive language with speech sound disorders;
  • intact comprehension;
  • lack anosognosia and/or auditory reception disorders;
  • no emotional lability

 

TARGETS:

  • to produce short, intelligible, and informative sentences with a natural prosody,
  • to imitate sentences accurately,
  • to produce 2-3 word sentences
  • to describe pictures
  • to answer questions

 

TECHNIQUES:

 

STIMULI: auditory, rhythmic

 

DOSAGE: varies average duration of therapy was 3 to 4 months

 

ADMINISTRATOR: SLP

 

PROCEDURES:

 

  • There are 3 stages for this intervention which begin as nonverbal and end in multiword utterances.

 

  • Stage I:

— C taps rhythms that are initially rhythmic and later varied and directs P to listen.

— C continues tapping but then asks P to imitate the rhythms. First there is a relatively long latency and then P gradually reduces the latency so that the tapping is conversation-like.

— C then adds humming (2 notes high and low) to the stimuli and P is expected to imitate the humming too. This exercise evolves in chant-like vocalizations

 

  • Stage II:

— C develops a corpus appropriate to Tunisian Arabic melody, rhythm, and stress. Utterances range from single words to sentences with varying length and complexity. The vocabulary is appropriate to daily living in Tunisia, although the authors did develop a corpus appropriate for educated Ps.

— C produces utterances and P listens.

— C directs P to imitate the utterance, gradually increasing length and complexity of the utterances to be modeled and gradually reducing P support. The target for acceptable production is all the elements of the model with the exception of articulatory accuracy.

 

  • Stage III:

— C introduces a question/answer activity in which the target is the natural use of prosody in spontaneous conversation.

 

RATIONALE/SUPPORT FOR INTERVENTION:

  • In the Introduction, the components of the intervention and its rationale are supported logically. In the discussion, the authors summarize some research about TMR and provide anecdotal information about their Ps.

 

CONTRAINDICATIONS FOR USE OF THE INTERVENTION:

  • None provided.