practice evidence - uwo.ca · impact of otitis media on later developing language skills in...

Practice

Evidence

School ofCommunication Sciences & Disorders

Procee!ngs of"e Fir# Annual CSD R$earch DayFebruary 11", 2%5

the First Annual CSD Research DayFriday, February 11th, 2005

Poster Session #1: 1:00pm to 2:00pm

PosterNo.

PageNo.

1 Effects of thalamic deep brain stimulation and topiramate medication on vocal, oral, and upper limb essential tremor.Adams, S., Jenkins, M.E., Dykstra, A.D., Howitz, N., Parrent, A., Jog, M.

1

2 Impact of otitis media on later developing language skills in children.Amlani, S.

2

3 The efficacy of oral myofunctional therapy on swallowing and speech difficulties.Anderson, M.M.

6

4 Effectiveness of directional microphones and digital noise reduction algorithms.Attridge, M.

9

5 Integrating frequency-specific ABR thresholds into the hearing instrument fitting process.Bagatto, M., Seewald, R., Scollie, S., Liu, R., Hyde, M.

13

6 Repeatability of a new technique for measuring the real-ear-to-coupler difference in young infants.Bagatto, M., Seewald, R., Scollie, S., Sinclair-Moodie, S.

14

7 The effectiveness of group therapy in improving functional communication in adults with aphasia.Beaton, J.

15

8 Evaluation of listener preference and intelligibility for a prototype electrolarynx.Beaudin, P.G., Meltzner, G., Doyle, P.C., Hillman, R.E., Symons, S.L., Reeves, A.

19

9 Psychophysical evaluation of pleasantness and acceptability for electrolaryngeal speech.Beaudin, P.G., Doyle, P.C., Eadie, T.L., Reeves, A.

20

10 The impact of PROMPT therapy on communication disorders.Boucher, J.

21

11 The efficacy of acute stroke dysphagia therapy.Cameron, M.S.

25

12 The impact of subjective thickening methods on individuals with dysphagia.Cowan, S.L.

29

13 Effectiveness of intervention methods for those diagnosed with auditory neuropathy / auditory dys-synchrony.D’Cunha, B.

33

14 Impact of writing therapy on functional communication in persons with aphasia.D’Souza, F.A.

36

15 Understanding the constructs underlying narrative comprehension in young children: The role of vocabulary.Dempsey, L., Lee, C., Skarakis-Doyle, E.

40

16 Written measures of voice handicap: A concurrent validity assessment of the VHI & VRQOL.Doyle, P.C., Beaudin, P.G., Eadie, T.L., Anderson, J., White, H.D.

41

17 Quantifying acoustic signal variability in adductor spasmodic dysphonia (ADSD).Doyle, P.C., Beaudin, P.G., DeLuca, M., Black, M., Eadie, T.L., Anderson, J., Lim, M., Luong, V.

42

18 Voice-related quality of life in alaryngeal speakers.Doyle, P.C., Eadie, T.L., Beaudin, P.G., White, H.D., Cagnin, D., Newell, C.

43

19 Music therapy and its effect on verbal expression in dementia.Freiburger, M.K.

44

20 Is there evidence to support treating language with intensive behavioral intervention programs such as ABA in childrenwith autism?Giberson, A.

48

21 The effectiveness of linguistic specific treatment on patients with agrammatic Broca’s aphasia.Gibson, K.L.

51

22 Efficacy of the Fast ForWord-Language intervention program.Grant, T.E.

54

23 Efficacy of melodic intonation therapy to increase functional communication in adults with nonverbal aphasia.Green, J.L.

57

Poster Session #2: 2:00pm to 3:00pm

PosterNo.

PageNo.

1 The role of dysphagia and prandial aspiration as predictors of aspiration pneumonia.Harty, J.D.

61

2 Is gastronomy a safe feeding alternative for children with neurodevelopmental disabilities?Heals, A.

65

3 The significance of age at cochlear implantation.Isaacs, S.

69

4 The accuracy and reliability of blue dye tests for predicting aspiration.Korzeniecki, T.A.

72

5 Impact of long-term pediatric tracheostomy on speech and language development.McGraw, C.

75

6 Efficacy of treatment approaches in developmental apraxia of speech.Meade, K.

79

7 The efficacy of different treatment approaches for Parkinsonian dysarthria.Miller, N.J.A.

83

8 Acoustic Signal Processing Research at the National Centre for AudiologyParsa, V.

87

9 Perceptual awareness and speech therapy treatment for patients with Parkinson’s disease.Perin, N.

88

10 Identifying and confirming the presence of auditory neuropathy / dys-synchrony.Philp, S.

92

11 Efficacy of thermal-tactile stimulation in dysphagia managementPicado-Goncalves, C.

96

12 Impact of animal assisted therapy on aggression in persons with dementia of the Alzheimer’s type.Pool, Emily

99

13 Evidence to support using parent-based intervention as a component of speech-language therapy for children.Price, A.M.

103

14 Clinical measurement of loudness discomfort levels.Ramlalsingh, T.R.

106

15 The desired sensation level (DSL) method in 2004: DSL m[i/o] version 5.0.Scollie, S., Seewald, R., Sinclair-Moodie, S., Cornelisse, L., Bagatto, M., Beaulac, S.

111

16 Do audiologic rehabilitation efforts have a positive impact on coping and communication?Sharma, R.

112

17 Identification of discourse comprehension impairments.Skarakis-Doyle, E., Dempsey, L., Lee, C.

115

18 Cochlear implants and optimizing speech perception.Sunney, C.A.

116

19 Oropharyngeal stimulation with air-pulse trains increases swallowing frequency.Theurer, J.A., Bihari, F., Barr, A.M., Martin, R.E.

120

20 Is there evidence to support using parent report as a screening tool for identifying children with speech and languagedelay?Thornton, B.

121

21 The impact of oral language delays on literacy development.Ustynsky, T.

124

22 The effectiveness of tinnitus retraining therapy.Vosper, J.

127

23 Improving the oral language foundation for reading: Phonological awareness and narrative skills.Washington, K., Warr-Leeper, G., Salazer, R.G., Gain, K., Koyanagi, K.

131

24 Voluntary swallowing in people who stutter.Webster, W.

132

Copyright © 2005, Adams, S., Jenkins, M.E., Dykstra, A.D., Howitz, N., Parrent, A., & Jog, M.S.

Effects of thalamic deep brain stimulation and topiramate medicationon vocal, oral and upper limb essential tremor

Adams, S., Ph.D.1, Jenkins, M.E., M.D.,2 Dykstra, A.D., M.Sc.3,Howitz, N.1, Parrent, A., M.D.2, Jog, M., M.D.2

1School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario2Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario3Doctoral Program in Rehabilitation Sciences, The University of Western Ontario, London, Ontario

This poster presents the results of two studies. In the first study, the effects of topiramate wereevaluated in an open-label study in 18 patients with essential tremor of the voice, tongue, jaw, andupper limb. All patients had been unresponsive to at least one other anti-tremor medication. Topiramate was started at 25 mg/day, titrated over 6 to 12 weeks to a maximum effective dose,and maintained at this dose for a minimum of 2 weeks prior to the final evaluation. The finaltopiramate doses ranged from 100 to 350 mg/day (mean dose 155 mg/day). Treatment effect wasmeasured using instrumental measures, a standard clinical rating scale for tremor, a perceptualrating of vocal tremor, and a quality of life visual analogue scale. Results demonstrated asignificant improvement in hand, jaw and voice tremor on both instrumental measures and clinicalrating of tremor. Patient self-ratings of tremor-related disabilities showed an improvement foractivities of daily living including eating, hygiene, and working. Patients also reported significantimprovement in quality of life measures. Side effects were a considerable factor in some patientsand may limit the use of topiramate in this population. This study demonstrated improvement invocal, jaw, and upper limb essential tremor with topiramate in a treatment resistant population.

In the second study, vocal, oral and limb tremors were examined in six individuals receivingthalamic deep brain stimulator (DBS) treatment for essential tremor. Subjects were evaluatedduring stimulator ‘on’ and ‘off’ conditions. The stimulator ‘on’ condition was associated with asignificant improvement in vocal tremor for the instrumental measures of tremor amplitude, andthe clinical ratings of tremor severity. Thalamic DBS had a greater and more consistent effect onvocal and jaw tremor than on tongue tremor. Perceptual speech ratings showed a slight reductionin speech intelligibility for the stimulator ‘on’ condition. The stimulator ‘on’ condition wasassociated with a significant improvement in upper limb tremor for the instrumental measures,clinical ratings, functional tasks and self-ratings. These results provide support for a focus onvocal and jaw tremor as primary treatment targets in future thalamic DBS procedures.

1

Copyright © 2005, Amlani, S.

Impact of otitis media onlater developing language skills in children

Amlani, S.M.Cl.Sc. (Aud) Candidate

School of Communication Sciences and Disorders, U.W.O.

This critical review examines the relationship between Otitis media (OM) in early childhood andlater developing language skills. All of the reviewed studies were identified as prospective,longitudinal, correlational designs. Each of the studies indicated little to no relationship betweenOM and language development, however, many of studies examined contained seriousmethodological, measurement, and statistical flaws. Therefore, there is an inadequate basis fordetermining whether or not prioritization of children with OM histories should be considered forspeech-language pathology (S-LP) services.

Introduction

Otitis media (OM) covers a variety of conditionsthat involve the presence of fluid within the middle-ear space. Each episode of acute otitis media isaccompanied by a period of effusion which may lastweeks or even months (Rvachew, Slawinski,Williams, and Green, 1999). Mild to moderatehearing loss may occur during any of the possibleacute or non-acute phases of the disease (Fria,Cantekin, and Eichler, 1985).

The linkage between otits media and laterdeveloping language delays is a controversial issue.While it is generally assumed that OM is associatedwith later developing lanugage delays, many studieshave been unable to relate an early childhood historyof OM to language development during the preschooland school-age years. There have been manyinconsistencies in study findings and methologicalproblems have surfaced. Research in this area isongoing, for several reasons. First, OM is one of themost frequently occuring illnesses in childhood, andit primarily occurs during the critical period in whicha child’s speech and language skills are developing(Burchinal,Roberts, and Zeisel, 2002). Children hearspeech sounds from their environment and begin toassociate meaning with these sounds, which thenforms the foundation of their developing language.Children with OM typically experience mild tomoderate fluctuating hearing loss and as a result, theymisperceive or miss sounds or words altogether.These “holes” in their knowledge base may impacttheir language learning (Burchinal et al., 2002). Ithas also been hypothesized that any areas ofdifficulty resulting from OM (such as language) willbe especially apparent during the school-aged years,when the child is faced with stresses of the schoolenvironment (i.e., reading, language based-subjects)(Burchinal et al., 2002).

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theimpact of OM on later developing language skills inyoung children. The secondary objective is topropose an evidence-based practice recommendationabout prioritization of children with a history of OMfor S-LP services.

Methods

Search StrategyStudies were found using computerized

databases, including CINAHL, Cochrane Library,Medline, PsycINFO, and PubMed. The searchstrategy utilized the following key words:

[(otitis media) OR (otitis media witheffusion) OR (OM) OR (OME)] AND[(language) OR (communication)] AND[(child*) OR (preschool) OR (school-aged)]

The search was limited to articles written inEnglish between 1990 and 2004.

Selection CriteriaAll studies selected for inclusion in this critical

review paper examined the impact of OM history onlater language development. The research studieswere selected without restrictions on demographicsor outcome measures.

Data CollectionThe literature search results yielded four articles

that employed prospective, longitudinal, correlationaldesigns.

2

IMPACT OF OTITIS MEDIA ON LATER DEVELOPING LANGUAGE SKILLS IN CHILDREN

Results

Impact of Otitis Media on Later LanguageDevelopment

Roberts et al. (2000) looked at the relationshipbetween children’s otitis media with effusion (OME)history during the first four years of life and the levelof growth in their language development from fouryears through second grade. A significantrelationship (p = 0.003) was reported between thehistory of early OME from six months to two yearsof age and lower expressive language (EL) scores atthe end of kindergarten. Using Pearson correlationstatistics, it was also determined that children withmore total OME six months to two years and sixmonths to four years scored lower on the CELF-P ELsubset at the end of kindergarten (r = -0.025 and r = -0.26, respectively). These r-values indicate little orno relationship of the variables. This weakassociation was not mentioned in the study’sinterpretation, which leaves the reader uncertain ofthe true correlation.

Paradise et al. (2000) were concerned with therelationship between children’s cumulative durationof middle ear effusion (MEE) in their first three yearsof life and their scores on measures of language.They found that mean developmental test scores atthree years of age were consistently highest in thelow-MEE group and consistently lowest in the high-MEE group, however none of the correlations werestatistically significant (p = 0.07 to 0.24). Pearsoncorrelations between individual children’s cumulativeproportions of total days with MEE and their scoresat three years of age on various developmentalmeasures were reported to be mainly negative, butgenerally weak (r = 0.21). Finally, all correlationsfor conversational sample analyses fell in the rangeof -0.08 to 0.2, which indicates little or norelationship existed between the variables, and all p-values fell above 0.05, indicating that the findingsmay be due to chance.

The study conducted by Feldman et al. (1999)addressed whether parent-reported levels of languageand communication skills at one and two years of agecorrelated negatively with the cumulative percentageof days with MEE. This study reported a significantcorrelation between the percentage of days withbilateral or total MEE in the second year of life andthe first two years of life combined and parent reportson the Vocabulary Production subset of theMacArthur Communicative Development Inventory(CDI) at two years of age (p = 0.03). After adjustingfor pertinent variables (e.g., age) no other significantcorrelations remained between results on the CDIsubsets and OM history. No statistically significantnegative correlations were found between parentreports of language levels and communication skills

at one year of age and the cumulative percentage ofdays with MEE in the first year of life.

Green et al. (1999) hypothesized that infantswith early-onset (EO) OM would demonstratesmaller canonical syllable ratios (CSRs) incomparison with infants who experienced no OMduring the first six months of life (LO). The EOgroup obtained lower mean CSRs at each age level incomparison with the LO group, and an ANOVArevealed significant main effects for both age (p =0.0001) and group (p = 0.0046).

The methodological problems that were seenacross all of the studies reviewed impacted the rigourof the results significantly. For example, childrenwho belonged to foster homes, possessed otherillnesses, had a low birth weight, had developmentaldeficits, etc. were excluded from all of the studies.This is concerning because many children who dosuffer from OM also, in fact, have these co-occurringdeficits or delays in other areas. Another flaw notedin all of the studies was the lack of inclusion of acontrol group. For research such as this, where anintervention is not being provided, there is littleethical concern for using a control group, thus, itshould have been a consideration in the research.

It was also found that most studies did not adjustfor known confounding variables (e.g., maternaleducation, social economic status, and childcareenvironment) that have been shown to explain aconsiderably larger portion of children’s languagedevelopment than OM. This is critical because onecannot be confident that the results of these studiesare in fact, due to OM.

The measurement tools used to assess languagedevelopment in these studies were questionable interms of appropriateness. Half of the studies failed toinclude a formal standardized test when assessing thechildren’s language abilities. These studies usedsolely parent-reported screening tools in the form ofquestionnaires and checklists to determine the child’slanguage functioning, which poses a major threat tothe validity. The results of these reports may havebeen overestimated due to parents’ lack of trainingand inability to notice subtle features of their child’slanguage use. Thus, the children’s language skillsmay have actually been poorer than reported, and therelationship between OM history and language couldhave been underestimated, which would greatlyaffect the results of these studies.

Thus, although none of the reviewed studieshave found OM history to be significantly related tolater language skills, all four of these studies hadserious methodological, measurement, and statisticalflaws. Since there is no evidence to prove that asignificant relationship between OM and laterlanguage development does exist, we wouldgenerally have to accept the null hypothesis, that is,

3


there is no existing relationship. However, given theresearch weaknesses, it is critical to continue researchin this area to determine whether or not OM does ordoes not impact later language development.

Prioritization of SL-P Services for children with OMhistory

From the literature reviewed, it is obvious thatthere are serious methodological flaws in currentresearch that are compromising the rigor of the studyresults. When combined with the statistical andmeasurement issues that were also found in thesestudies, the results become highly questionable.Thus, there is reason to further investigate therelationship between OM and language. Based onthis belief, it is recommended that the notion ofprioritization of S-LP services for these children notbe discarded until more rigorous research supports ordenies this.

From the literature, it was discovered that OMhistory does impact early language (i.e. reducedcanonical syllable ratios (CSRs)); thus, we can nowdetermine at a very early age, who may potentially beat risk for later language development. Earlyintervention is supported by this research, andtherefore this study is valuable in terms of clinicalrelevance. However, more research must becompleted to determine if these reduced CSRs are, infact, related to later language development before wecan be certain of the long-term effect of treatment forthese babies.

Conclusions

It should be recognized that although earlierretrospective studies of the OME-language learningrelationship had many methodological problems,more recent studies avoided many of these problemsby following children prospectively. However, inusing the prospective design to study these subjects,many other methodological, measurement, andstatistical flaws have surfaced which havecompromised the rigor of the studies and put theminto question. Further research should focus onimproving methodology (e.g., using exclusionarycriteria for subject selection that does not discountthe great deal of the population at risk, use of controlgroups, etc.), use of appropriate measurement tools(e.g., increasing the use of standardized tests tocompliment screening tools), and statistically relatedissues as mentioned previously such that the resultsof the studies can guide us to answers regarding theusefulness of prioritization for children with OMhistories for S-LP services.

References

Bates, E., Dale, P. S., Fenson, L., Hartung, J. P.,Pethick, S., Reilly, J. S., Reznick, J. S., & Thal,D., (1997). MacArthur CommunicativeDevelopment Inventory. Retrieved October 11th,2004 from http://www.med.unc.edu/

Bernard, B. S., Campbell T. F., Colborn, D. K,Dollaghan, C. A., Feldman, H. M., Janosky, J.E., Kurs-Lasky, M. S., Paradise, Pitcairn, D.L., J.L., Rockette, H.E., Sabo, D.L., & Smith, C.G.(2000). Language, speech sound production andcognition in three-year-old children in relation tootitis media in their first three years of life.Journal of Paediatrics, 105, 1119-1130.

Bornstein M.H., Haynes M.O., & Painter K.M.(1998). Sources of ++child vocabularycompetence: a multivariate model. Journal ofChild Language, 25, 367-393.

Burchinal, M. R., Roberts, J. E., & Zeisel, S. A.(2002). Otitis media in early childhood inrelation to children's school-age language andacademic skills. Journal of Pediatrics, 110, 1-11.

Bzoch, K. R., & League R (1991). Examiner’sManual: Receptive-Expressive EmergentLanguage Test. Austin:TX: Pro-Ed Inc.

Campbell, T. F., Colborn, D. K., Dollaghan, C. A.,Feldman, H. M., Janosky, J. E., Kurs-Lasky, M.S., & Paradise, J. L. (1999). Parent-reportedlanguage and communication skills at one andtwo years of age in relation to otitis media in thefirst two years of life. Journal of Pediatrics, 104,1-6.

Dunn, L. M., & Dunn, L. M. (1981). Peabody PictureVocabulary Test-Revised.Circle Pines, MN: American Guidance.

Green, C., Rvachew, S., Slawinski, E.B., &Williams,M. (1999). The impact of early onset otitis mediaon babbling and early language development.Journal of the Acoustic Society of America, 105,467-475

Feldman H.M., Dollaghan C.A., Campbell T.F.,Colborn D.K., Kurs-Lasky M, Janosky J.E., &Paradise, J.L. (1999). Parent-reported languageand communication skills at one and two yearsof age in relation to otitis media in the first twoyears of life. Pediatrics, f 104, 4.

Fria T.J., Cantekin E.I., Eichler J.A. (1985). Hearingacuity of children with otitis media witheffusion. Archives of Otolaryngology, 111, 10-16.

Gravel J.S., Wallace I.F. (1998). Listening Language,Speech, and Educational Outcomes of Otitismedia. Journal of Otololaryngology, 27, 17-23.

4


Mather, N. & Woodcock, R. W. (2001). Examiner’sManual: Woodcock-Johnson III Tests ofCognitive Abilities. Itasca, IL: RiversidePublishing.

Maw R., Wilks J., Harvey I., Peters T..J., Golding J.(1999). Early surgery compared with watchfulwaiting for glue ear and effect on languagedevelopment in preschool children: a randomizedtrial. Lancet, 353, 960-963

McCauley, R., & Swisher, L. (1984). Psychometricreview of language and articulation tests forpreschool children. Journal of Speech andHearing Disorders, 49, 34-42.

Paradise J.L., Dollaghan C.A., Campbell T.F.,Feldman H.M., Bernard B.S., Colborn D.K.,Rockette H.E., Janosky J.E., Pitcairn D.L., SaboD.L., Kurs-Lasky M., Smith C.C. (2000).Language, speech sound production, andcognition in three-year-old children in relation tootitis media in the first three years of life.Pediatrics, 105, 1119-1130.

Paul, R. (2001). Language disorders from infancythrough adolescence. (2nd ed). St. Louis, MO:Mosby.

Plante, E., & Vance, R. (1994). Selection ofpreschool language tests: a data-based

approach. Language, Speech, and HearingServices in Schools, 25, 15-24.

Roberts J.E., Burchinal M.R., Jackson S.C., HooperS.R., Roush J., Mundy M., Neebe E.C., ZeiselS.A. (2000). Otitis media in childhood in relationto preschool language and school readiness skillsamong black children. Pediatrics, 106, 725-735.

Roberts J.E., Burchinal M.R., Zeisal S.A. (2002).Otitis media in early childhood in relation tochildren’s school-age language and academicskills. Pediatrics, 34, 1158-1168.

Rvachew S., Slawinski E.B., Williams M., GreenC.L. (1999) The impact of early onset otitismedia on babbling and eary languagedevelopment. Journal of the Acoustic Society ofAmerica, 105, 467-475.

Schonweiler R., Ptok M., Radu H.J. (1998). A cross-sectional study of speech- and language-abilitiesof children with nomral hearing, mild fluctuatingconductive hearing loss, or moderate to profoundsensoneurinal hearing loss. InternationalJournal of Pediatric Otorhinolaryngology, 44,251-258.

Semel, E., Wiig, E. H., & Secord, W. A. (1995).Clinical Evaluation of Language Fundamentals:Three, (3rd ed). San Antonio, TX: ThePsychological Corporation.

5

Copyright © 2005, Anderson, M.M.

The efficacy of oral myofunctional therapy onswallowing and speech difficulties

Anderson, M.M.M.Cl.Sc. (SLP) Candidate


This critical review examines the effects of oral myofunctional therapy among persons withswallowing and speech disorders. Study designs include: critical review, a randomized controlledtrial, and pre- post test designs. Overall, research supports the use of oral myofunctional therapy asa treatment for tongue thrust; however, not as a sole treatment for speech difficulties.

Introduction

Since the 1970’s, when the debate began aboutthe existence of tongue-thrust and its therapy, speechpathology programs and clinicians have avoideddealing with oral myofunctional therapy. However,with ASHA’s 1991 positive statement on “The Roleof the Speech-Language Pathologist in Assessmentand Management of Oral Myofunctional Disorders,this has been shifting (Landis, 1994). Since than, anincrease in the awareness and interest ofmyofunctional disorders has been seen.

An orofacial myofunctional disorders is anypattern involving oral and/or orofacial musculaturethat interferes with normal growth, development orfunction of structures or calls attention to it (ASHA,1993). Dentists and orthodontists have for manyyears been the experts from whom we seek advice onoral structure, oral care, and and related problems.Because dentition can be affected by the pressuresexerted on it by the tongue at rest and duringswallowing, dentists have turned to the speechpathologist for assistance in developing treatmentprograms (Pierce, 1980). Orofacial myofunctionaldisorder variables are classified as lingual, labial,dental and skeletal factors, soft tissue differences,oral habits, mouth-breathing, lips-apart rest postures,and speech differences (Kellum, 1994).Myofunctional therapy provides increasingawareness of and exercises for these muscles (of thetongue, cheek, lips, and jaw); it also focuses onorofacial muscle tone and rest posture (Landis, 1994).

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theimpact of oral myofunctional therapy on individualswith tongue thrust and speech difficulties.

Methods

Search StrategyComputerized databases, including CINAHL,

PubMed, and The University of Toronto Library,were searched using the following search strategy:

((Swallowing Disorders) OR (Dysphagia))AND ((Oral myofunctional Therapy) OR(OMT) OR (oromyofunctional therapy)).


Selection CriteriaStudies selected for inclusion in this critical

review paper were required to investigate the impactof any type of oral myofunctional therapy programon the tongue thrust swallowing pattern, articulationerrors (eg. sibilant /s/ distortion), and intelligibilityissues. No limits were set on the demographics ofresearch participants or outcome measures.

Data CollectionResults of the literature search yielded the

following types of articles congruent with theaforementioned selection criteria: clinical exchangearticle (1), critical review and randomized controlledtrial (RCT) (1), pre- post-test design (2), and an ABCrepeated measures design (1).

Results

Overstake (as cited in Pierce, 1980) used arandomized controlled trial design to examine theeffects that tongue thrust therapy (subgroup 1), ortongue thrust plus speech therapy (subgroup 2),would have on the misarticulation of /s/ (i.e. lisping).86% of the participants in subgroup 1 that completedthe study had corrected the /s/ sound in unguarded,conversational speech (24 out of 28), and 75% of theparticipants in subgroup 2 had habituated a normal /s/(15 out of 20).

Ray (2002) conducted a pretherapy – posttherapycomparison study is to examine the influence OMT

6

THE EFFICACY OF ORAL MYOFUNCTIONAL THERAPY ON SWALLOWING AND SPEECH DIFFICULTIES

has on speech intelligibility and a speechdiadochokinetic task, without direct articulatorydrills. A Wilcoxon signed rank test was computed,which indicated no significant difference (z = 0.44)for sentence and conversational speech. This findingwas attributed to sentence length and complexity.Qualitative improvements were, however, reportedfor sentence and conversational speech intelligibility.Finally, a significant improvement was reported forsingle words.

Ray (2003) also conducted a pretherapy –posttherapy comparison to examine the effects thatorofacial myofunctional therapy (OMT) had onpersistent articulation impairments and various co-existing (i.e., previously treated) orofacialmyofunctional disorders. All clients were able tomaintain appropriate lip and tongue postures, 70% ofthe time, and heightened awareness of tongue and lippositions was developed. 5/6 subjects revealed:

• 25% increase in single word intelligibility(27/30)

• 15% increase in sentence intelligibility(7.5/10)

• 12% increase for spontaneous speech(175/250)

This data was used to calculate McNemar testsfor each outcome measure, revealing significantimprovement for single words (χ2 = 7.81), andspontaneous speech (χ 2 = 17.5). Sentenceintelligibility demonstrated no significantimprovement (χ2 = 1.07).

Ray (2003) excluded the data from one subjectwith a class III malocclusion and developmentalapraxia of speech, because the subject failed toperform adequately during the post-treatmentmeasures. Ray (2003) also noted that the clientrepresented a good exemplar of someone with“persistent sound system disorders” or “persistentarticulatory impairments” (Powell, 1996; Ray, 2003;Shelton, 1993). Despite this exclusion, however, theauthor concluded that the study suggest OMT iseffective in treating individuals with persistentarticulatory impairments and occlusion problems.

Speech intelligibility was reported to improvefrom 61% to 78.3% of an utterance (based on themethod of transcription), and transcription scoreswere noted to vary significantly from pre- to post-therapy.

Gommerman & Hodge (1995) used an ABCsingle subject design to investigate the effectivenessof oral myofunctional therapy in eliminating tonguethrust swallowing pattern with mild sibilantdistortion, in a 16-year old female patient. They useddiadochokinetic rate as a control for maturation, anddemonstrated no significant temporal effects,effectively eliminating this bias. Their outcome

measures included frequency of tongue thrustswallows, duration of swallows, ease/naturalness ofthe swallowing pattern, sibilant distortion, tonguestrength, and tongue endurance. Their results were asfollows:

• Frequency of tongue thrust swallows:Baseline – 100%OMT – 0% after 1st sessionDuring articulation therapy – 0%

• Duration of Swallows: A celeration line wasused to determine the slope. They found anincrease in the efficiency of normalswallows (session 3, 6, and 9 not availabledue to equipment failure). Phase C(articulation treatment) showed an increasein time and there was sigh session-to-sessionvariability (e.g. 23 sec in session 22 and 36sec in session 36).

• Ease/Naturalness of swallowing pattern: Anincreasing trend was found using self-rating.

• Sibilant distortion:Baseline – 1-9%OMT – 0-9%Celeration points indicate a slight increasingtrend for both baseline and OMT (session11&12 no values due to equipmentmalfunctionArticulation – 9%(1st session) and 1-3% (infinal 3)

• Tongue strength: The IOPI was used todetermine strength, and an increase acrossthe 3 phases was seen. They also comparedexpected strength (based on weight) with theactual strength.Phase A – the mean was 34.6 (which isbelow the expected value) and an increase of15kPa (49.5kPa) was seen. This affects theinterpretation of the increase in measures oftongue strength that was observed in PhaseB and C.Phase B – an increase in strength wasobservedPhase C – an increase was again found(65kPa which is above the norm).

• Tongue Endurance:Phase A – showed an increase in stability atbaseline, which may have been due toincreased effort or increased familiarity andproficiency with the task.Phase B – Increase in enduranceThese results suggest the exercisesperformed during OMT had positive effectson endurance and possibly strength.

Gommerman and Hodge (1995) also employedan in-home follow-up evaluation, 2 and 4 weeks aftercompleting phase C. Normal swallows were

7

THE EFFICACY OF ORAL MYOFUNCTIONAL THERAPY ON SWALLOWING AND SPEECH DIFFICULTIES

observed while the subject ate dinner and drankliquids. Another follow-up was conducted 6 monthsafter the end of the study to assess maintenance ofskills (swallowing and articulation). A normalswallow was observed on all 10 trials (completed in22 sec and were judged to be 100% natural) and 0%sibilant distortion was observed. Maximal tonguestrength was within the norm for her weight(61.25kPa), but tongue endurance had decreased(from a mean of 21.5 sec at end of phase C to 15.25sec). This decrease placed the subject below theexpected value for children, but above her baselinemeasures (11-13 sec above baseline). The authorssuggest that fatigue or reduced effort may account forthe lower values observed.

Conclusions

Gommerman & Hodge (1995) concluded thatoral myofunctional therapy was effective ineliminating the subject’s tongue thrust pattern.Furthermore, while it did not eliminate the client’ssibilant distortion, it may have facilitated her skill incombining appropriate lingual articulatory placementwith ear training for undistorted sibilant productions.Ray (2003) concluded that OMT is effective intreating individuals with persistent articulatoryimpairments and occlusion problems. Speechintelligibility was reported to improve from 61% to78.3% of an utterance (based on the method oftranscription), and transcription scores were noted tovary significantly from pre- to post-therapy.

The existing literature on OMT does not,therefore, unanimously agree on the effectiveness ofOMT in treating articulation problems. They do,however, agree that OMT has a significant impact ontongue thrust swallowing pattern. This suggests thata combination therapy, involving OMT for thetreatment of structural or physical abnormality, andarticulation therapy for the treatment of articulatorydisorders.

This review also underscores the importance ofidentifying structural or physical abnormalities thatmay impede the success of traditional SLPinterventions. It also suggests that workingcollaboratively with dentists and orthodontists to treatthese underlying issues may help to facilitatetreatment efficacy in speech therapy. Furtherresearch (longitudinal and retrospective) on the use oforal myofunctional therapy in treating swallowingand articulatory disorders, as well as studiesexamining the efficacy of OMT for articulationdisorders (in the absence of orofacial myofunctionaldisorders), is needed.

References

Bacha, S.M., and Rispoli, C.F. (1999).Myofunctional Therapy: Brief Intervention.International Journal of Orofacial Myology.25:37-47, Nov.

Gommerman, S.L., and Hodge, M.M. (1995). Effectsof Oral Myofunctional Therapy on Swallowingand Sibilant Production. International Journal ofOrofacial Myology. 21:9-22, Nov.

Landis, C.F. (1994). Applications of OrofacialMyofunctional Techniques to Speech Therapy.International Journal of Orofacial Myology.20:40-51, Nov.

Marchesan, I.Q. (2000). The Speech PathologyTreatment with Alterations of theStomatognathic System. International Journal ofOrofacial Myology. 26:5-12, Nov.

Pierce, R.B. (1980). The role of MyofunctionalTherapy in Speech Pathology. InternationalJournal of Orofacial Myology. 6(4): 11-3, Oct.

Ray, J. (2002). Orofacial Myofunctional Therapy inDysarthria: A Study on Speech Intelligibility.International Journal of Orofacial Myology.28:39-48, Nov.

Ray, J. (2003). Effects of Orofacial MyofunctionalTherapy on Speech Intelligibility in Individualswith Persistent Articulatory Impairments.International Journal of Orofacial Myology.29:5-14, Nov.

8

Copyright © 2005, Attridge, M.

Effectiveness of directional microphones anddigital noise reduction algorithms

Attridge, M.M.Cl.Sc. (Aud) Candidate


This critical review examines the effectiveness of directional microphones and digital noisereduction algorithms in improving speech intelligibility in the presence of background noise.Study designs include: review article, repeated measures within subject design, and meta-analysis.Overall, research suggests that directional microphones are capable of improving the signal tonoise ratio of speech in noise; however, digital noise reduction algorithms were not found tosignificantly improve speech intelligibility in noise.

Introduction

One of the most common complaints of hearinginstrument wearers is difficulty listening to speech inthe presence of background noise. While hearinginstruments allow for the audibility of desiredsounds, they do so at the cost of also makingunwanted sounds available to the listener. Thisproves especially problematic for the impairedcochlea. Individuals with sensorineural hearing lossrequire a higher signal-to-noise ratio (SNR) forspeech intelligibility than normal hearing listeners.Furthermore, the greater the degree of hearing loss,the higher the SNR required for speech intelligibility.Therefore, it is necessary to consider hearinginstruments technologies that serve to increase theSNR for speech intelligibility in the presence ofbackground noise. There are currently two mainapproached to noise reduction in hearing instruments,directional microphones and digital noise reduction(DNR) algorithms.

Developments in hearing instrument microphonetechnology have brought directional microphonesfrom a single microphone two port system to a multi-microphone digital signal processing system. Thisnew era of directional microphones includes bothfixed and adaptive array systems. Only fixed arraydirectional microphones will be considered in thepresent investigation as literature on adaptive systemsis limited and evolving. In fixed array systems, twoor more omnidirectional microphones are positionedon the hearing instrument. Signal processingalgorithms cause sound entering the rear microphoneto be delayed and thus out of phase with soundentering the front microphone. When the inputs fromboth microphones are added together, the phaseopposition causes a canceling of the sound collectedfrom the rear microphone.

Digital noise reduction (DNR) algorithms, orsingle microphone technologies, take advantage ofthe characteristic spectral and temporal differences

between a speech signal and a noise source.Incoming signals can be recognized as either speechor noise, and can be manipulated according to theparticular DNR algorithm of the hearing instrument.

It is important as clinicians that we remainabreast of current advances in hearing instrumenttechnologies and the efficacy of such technologies.The issue of listening in background noise is ofutmost importance to hearing instrument wearers, andin turn becomes a major concern for the dispensingaudiologist. Critical analysis of research on theefficacy of noise reduction technologies allows forinformed decision-making during hearing instrumentprescription.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theeffectiveness of directional microphones and digitalnoise reduction algorithms in improving speechintelligibility in the presence of noise. The secondaryobjective is to propose evidence-based practicerecommendations regarding the prescription of suchtechnologies in hearing instruments, as well as thecounseling of clients making use of suchtechnologies.

Methods

Search StrategyCompute r i zed da tabases , inc lud ing

ComDisDome, and PubMed, were searched using thefollowing search strategies:

((directional microphone) OR (dualmicrophones) OR (multi-microphone))AND ((hearing aid) OR (hearinginstrument))((digital noise reduction) OR (digital noisereduction algorithm) OR (noise reduction)

9

EFFECTIVENESS OF DIRECTIONAL MICROPHONES AND DIGITAL NOISE REDUCTION ALGORITHMS

OR (noise reduction algorithm)) AND((hearing aid) OR (hearing instrument)).



review paper were required to investigate theeffectiveness of directional microphones and/ordigital noise reduction algorithms in improving thesignal to noise ratio of speech in noise. No limitswere set on the demographics of research participantsor outcome measures.


following types of articles congruent with theaforementioned selection criteria: review (4),repeated measures within subjects design (10), andmeta-analysis (1).

Observed MethodologiesWith such a large body of research, some trends

in study design were observed. A repeated measureswithin subjects design was used in all studies underconsideration. Results were generally analyzed usingone-, two-, or three-way repeated measures analysisof variance (ANOVA), Tukey’s honestly significantdifference (HSD) and paired t-tests for investigationof interactions. There are two avenues, objectiveand/or subjective measures, by which measures ofefficacy were obtained in both directionalmicrophone and DNR algorithm studies.

Objective measures used in the literature includethe Hearing in Noise Test (HINT), the Speech inNoise (SIN) test, the Connected Speech Test (CST),and various other speech reception tests administeredin the presence of noise. These measures provided anindication of the benefit of the noise reductionstrategies through an individual’s performance on thegiven task. A SNR can often be calculated from suchtests and this then provided a decibel differenceindication of the benefit of the technology.

Self assessment scales, administered before andafter a noise reduction strategy is implemented, wereused to provide investigators with an indication of thetechnology’s benefit. Use of the Profile of HearingAid Benefit (PHAB), the Abbreviated Profile ofHearing Aid Benefit (APHAB), and other self-reportmeasures generated by the investigators, was foundin the literature. These outcome measures were usedto provide an indication of the subjective experienceof a particular technology.

Ideal MethodologyWhen answering the question of how to measure

the benefit of a noise reduction strategy, it is believedthat an investigator should use both objective andsubjective measures of the technology’s benefit.

Objective measures, such as the HINT, thatallow for SNR assessment of the advantage providedby the technology are preferable. Tests that canapproximate real-world situations through their useof sentence material and the ability to vary the noiseconfiguration allow for greater generalizability ofresults.

Although, many researchers may questionadvocacy of the use of subjective measures, it isbelieved that such information is clinically andcommercially relevant. Therefore, investigationsincorporating subjective measures are notunwarranted. Bentler et al (2003) demonstrated thatparticipants are affected by the labeling of hearinginstrument technology. It is therefore suggested thatoutcome measures, such as the PHAB or APHAB, beconducted in a double-blind manner in order to avoidlabeling effects when assessing new technology.

The preferred study design in assessing hearinginstrument technology benefit would be arandomized control trial. However, it is oftendifficult to implement this in audiologic research asmatching participants in experimental and controlgroups is complicated by hearing loss configurationand speech perception abilities. Therefore, a repeatedmeasures within subject design is preferred.

Directional microphones and DNR algorithmsshould be evaluated using multiple trials undervarying reverberation times and noise conditions (ie.number of noise sources, noise source configurations,and noise characteristics). In studying the noisereduction strategy under a variety of conditions, wemay develop a better indication of its real-worldperformance and potential benefit.

Results

When considering the research into directionalmicrophones and DNR algorithms, it is necessary toappraise their contributions based on the degree ofexperimental control, the generalizability of theresults to the real-world, and the appropriate use ofstatistical analyses. The studies under examinationwere assessed with regards to the aforementionedcriteria and the contributions of each study wereweighed accordingly.

Only objective measures of improved speechintelligibility, as expressed as improved SNR, wereconsidered in this investigation. Subjective measuresare easily confounded if not conducted in a blinded

10


manner (Bentler et al, 2003). The studies underinvestigation could not claim effective blinding.

In any investigation involving the assessment ofhearing instrument technology, it is necessary toconsider possible involvement of manufacturers inthe funding and execution of the research. It isimportant as a consumer of the literature that oneconsiders any possible biases that may stem frommanufacturer involvement. Seven of the eightstudies involving research reported funding by ahearing instrument manufacturer.

Directional Microphone EfficacyThe following five studies were considered:

Amlani, 2001; Pumford et al, 2000; Ricketts & Dhar,1999; Ricketts & Mueller, 2000; and Valente et al,1995. Although all were very similar in experimentaldesign and analysis, save Amlani (2001) which is ameta-analysis, a few studies can be seen todemonstrate good experimental control andgeneralizability (Pumford et al, 2000; Ricketts &Dhar, 1999; Ricketts & Mueller, 2000). Thesestudies provided the basis for the conclusions drawnabout the benefit provided by directional technology.All the studies used appropriate statistical analyses inthe form of a one-, two-, or three-way repeatedmeasures analysis of variance (ANOVA), Tukey’shonestly significant difference (HSD) and paired t-tests for investigation of interactions.

Through critical analysis of the results of thesestudies, it is can be seen that directional microphonesindeed provide an advantage, as expressed in SNR,over omnidirectional microphones. Directionalsystems can provide approximately 0.5 to 6.5 dBSNR in moderately reverberant environments and 0.8to 7.5 dB SNR under anechoic/low-reverberationconditions (Pumford et al, 2000; Ricketts & Dhar,1999; Ricketts & Mueller, 2000). It is important tonote here that Ricketts & Mueller (2000) investigatedseveral factors (threshold slope, high frequencyaverage threshold, and omnidirectional speechintelligibility) for their predictive value in directionalbenefit. It was found that such factors cannotsignificantly predict the amount of benefit anindividual will receive from a directional microphonesystem.

Digital Noise Reduction Algorithm EfficacyThe following four studies looking at DNR

algorithms were considered in this paper: Alcantaraet al, 2003; Boymans & Dreschler, 2000; Jamieson etal, 1995; and Walden et al, 2000. Data regarding thebenefit of DNR algorithms can also be found in someof the studies examined above as they analyzed suchalgorithms as variables (Pumford et al, 2000; Ricketts& Dhar, 1999; Valente et al, 1995). These studies,

and the aforementioned studies, will provide the basisfor the conclusions drawn about the benefit providedby DNR algorithms. Unlike the studies ondirectional microphones, these studies were lesssimilar in experimental design. All the studies usedappropriate statistical analyses in the form of a one-,two-, or three-way repeated measures analysis ofvariance (ANOVA), Tukey’s honestly significantdifference (HSD) and paired t-tests for investigationof interactions.

These studies evaluated participants’performance under a variety of noise conditions.This is an extremely important consideration in thisarea of research, as these algorithms seek to eliminatenoises with particular characteristics. Overall, thestudies considered here do not provide evidence forthe effectiveness of DNR algorithms in providingmore favourable SNR ratios (Alcantara et al, 2003;Boymans & Dreschler, 2000; Jamieson et al, 1995;Pumford et al, 2000; Ricketts & Dhar, 1999; Valenteet al, 1995; Walden et al, 2000).

Although subjective measures were not fullyexamined in this review, their results are worthmentioning with regards to DNR algorithms.Research consistently shows hearing instrumentwearers report greater comfort in the presence ofnoise with DNR algorithms activated (Boymans &Dreschler, 2000; Jamieson et al, 1995; and Walden etal, 2000).

Conclusions

From this critical analysis of the literature,certain statements can be made regarding the efficacyof directional microphones and DNR algorithms inimproving speech intelligibility in noise. Theliterature has shown that it is only directionalmicrophones that provide this benefit. Directionalmicrophones can provide a SNR improve in the rangeof approximately 0.5 to 6.5 dB SNR in moderatelyreverberant environments and 0.8 to 7.5 dB SNRunder anechoic/low reverberant conditions (Pumfordet al, 2000; Ricketts & Dhar, 1999; Ricketts &Mueller, 2000). DNR algorithms did notsignificantly improve the SNR (Alcantara et al, 2003;Boymans & Dreschler, 2000; Jamieson et al, 1995;Pumford et al, 2000; Ricketts & Dhar, 1999; Valenteet al, 1995; Walden et al, 2000). However, DNRalgorithms may provide some benefit to hearinginstrument wearers in the form of improved listeningcomfort in the presence of background noise(Boymans & Dreschler, 2000; Jamieson et al, 1995;and Walden et al, 2000).

Clinicians are ‘front-line’ in this field andtherefore the implications of an investigation such asthis should be considered. Recommendations forclinicians address informed prescription of hearing

11


instruments and their associated technologies, andeducation and counseling of clients with regards tothe expected benefit of these technologies.

As with any area of practice, a clinician needs totake efforts to provide appropriate evidence-basedhearing instrument prescription. There is also a needto educate our clients throughout the hearinginstrument prescriptive process, as some areenthusiastic consumers of marketing literatureprovided by the manufacturers. The cost-effectiveness of such technologies needs greatconsideration and should be shared with the clients.Review of the literature on DNR algorithm hasdemonstrated a failure to increase speechintelligibility in noise and failure to provide a morefavourable SNR. Clinicians who seek to increase aclient’s speech understanding in noise shouldtherefore not prescribe a high end digital instrumentonly because it offers a DNR algorithm when a lowerend digital instrument with addition of a directionalmicrophone would be more beneficial. As clinicians,we must stay informed of the efficacy of hearinginstrument technologies and not be easily swayed bymarketing in our hearing instrument prescriptions.

Finally, clinicians are the client’s liaison withhearing instrument manufacturers and the researchcommunity. As such, it is our responsibility toprovide our clients with an unbiased and educatedinterpretation of the marketing of hearing instrumenttechnologies. Should we prescribe a hearinginstrument that offers a directional microphoneand/or a DNR algorithm, we need to provideeffective counseling regarding the expected benefit ofthose technologies. It should be made clear to theclient that the directional microphone can offer betterspeech understanding in noise, but that the DNRalgorithm only offers a more comfortable listeningprogram. Also, the literature has shown differentialperformance of directional microphones in highversus low reverberant conditions. Thereforecounseling should include discussion surrounding thedifferent benefit that may be experienced in variousreal-world environments. In addition to counselingsurrounding the expected benefit, clinicians shouldtake care to educate clients on the effective use of thetechnologies. It is important for a clinician toremember that a hearing instrument wearer can onlybenefit from the technology if they know how andwhen to implement it.

References

Alcantara, J. L., Moore, B. C., Kuhnel, V., & Launer,S. (2003). Evaluation of the Noise ReductionSystem in a Commercial Digital Hearing Aid.International Journal of Audiology, 42(1), 34-42.

Amlani, A. M. (2001). Efficacy of DirectionalMicrophone Hearing Aids: A Meta-AnalyticPerspective. Journal of the American Academyof Audiology, 12, 202-214.

Bentler, R. A., Niebuhr, D. P., Johnson, T. A., &Flamme, G. A. (2003). Impact of DigitalLabeling on Outcome Measures. Ear &Hearing, 24 (3), 215-224.

Bentler, R. A., Tubbs, J. L., Egge, J. L. M., &Dittberner, A. B. (2004). Evaluation of anAdaptive Directional System in a DSP HearingAid. Journal of the American Academy ofAudiology, 13 (1), 73-79.

Boymans, M., & Dreschler, W. A. (2000). FieldTrials Using a Digital Hearing Aid with ActiveNoise Reduction and Dual-MicrophoneDirectionality. Audiology, 39(5), 260-268.

Byrne, D. (1998). Hearing Aid Clinical Trials:Specific Benefits Need Specific Measures.American Journal of Audiology, 7(1), 17-19.

Jamieson, D. G., Brennan, R. L., & Cornelisse, L. E.(1995). Ear & Hearing, 16, 274-286.

Levitt, H. (2001). Noise reduction in hearing aids: areview. Journal of Rehabilitation Research andDevelopment, 38 (1), 111-121.

Pumford, J. M., Seewald, R. C., Scollie, S. D., &Jenstad, L. M. (2000). Speech Recognition withIn-the-Ear and Behind-the-Ear Dual-MicrophoneHearing Instruments. Journal of the AmericanAcademy of Audiology, 11 (1), 23-35.

Ricketts, T., & Dhar, S. (1999). Comparison ofPerformance Across Three Directional HearingAids. Journal of the American Academy ofAudiology, 10 (4), 180-189.

Ricketts, T., & Mueller, H. G. (2000). PredictingDirectional Hearing Aid Benefit for IndividualListeners. Journal of the American Academy ofAudiology, 11 (10), 561-569.

Valente, M., Fabry, D. A., & Potts, L. G. (1995).Recognition of Speech in Noise with HearingAids Using Dual Microphones. Journal of theAmerican Academy of Audiology, 6, 440-449.

Walden, B. E. (1998). Toward a Model of Clinical-Trials Protocol for Substantiating Hearing AidUser-Benefit Claims. American Journal ofAudiology, 6(2), 13-24.

Walden, B. E. (1998). Response to Byrne. AmericanJournal of Audiology, 7(1), 20-23.

Walden, B. E., Surr, R. K., Cord, M. T., Edwards, B.,& Olson, L. (2000). Comparison of BenefitsProvided by Different Hearing AidTechnologies. Journal of the American Academyof Audiology, 11 (10), 540-560., 11 (10), 540-560.

12

Copyright © 2005, Bagatto, M., Seewald, R., Scollie, S., Liu, R., & Hyde, M.

Integrating frequency-specific ABR thresholdsinto the hearing instrument fitting process

Bagatto, M., M.Cl.Sc.1, Seewald, R., Ph.D.1,2, Scollie, S., Ph.D.1,2, Liu, R.1, Hyde, M., Ph.D.3

1National Centre for Audiology, The University of Western Ontario, London, Ontario2School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario3Otologic Function Unit, Mount Sinai Hospital, Toronto, Ontario

For very young infants, estimates of hearing sensitivity are derived from auditory brainstemresponse (ABR) measurements. These electrophysiological procedures have not been developed toanticipate the computational requirements of hearing aid prescription algorithms. Consequently,the ABR threshold estimates cannot be entered directly into hearing aid prescription softwarewithout correction. Typically, a published correction is subtracted from the ABR (dB nHL)measurements of the infant’s hearing sensitivity and the resulting Estimated Hearing Level (dBeHL) is used to calculate the hearing aid prescription.

The results of a laboratory evaluation of ABR corrections for adults with normal hearing andchildren with sensorineural hearing loss will be presented. The findings indicate that by measuringthe acoustic properties of individual ear canals, accurate conversions of nHL to real-ear SPL arepossible. In addition, these converted values can be compared to behavioural SPL thresholds witha reasonable degree of accuracy by applying previously determined corrections. This newprocedure for predicting the real-ear SPL of ABR test signals will provide a better understandingof their accuracy for use in hearing aid prescription algorithms.

Funded by the Canadian Language and Literacy Network

13

Copyright © 2005, Bagatto, M., Seewald, R., Scollie, S., & Sinclair-Moodie, S.

Repeatability of a new technique for measuringthe real-ear-to-coupler difference in young infants

Bagatto, M., M.Cl.Sc.1, Seewald, R., Ph.D.1,2, Scollie, S., Ph.D.1,2, Sinclair-Moodie, S., M.Cl.Sc.1

1National Centre for Audiology, The University of Western Ontario, London, Ontario2School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario

The real-ear-to-coupler difference (RECD) is a reliable and valid clinical procedure used forfitting amplification to infants and young children. With the advent of universal newborn hearingprograms, RECDs from young infants are used as part of an accurate intervention protocol (eg.,AAA protocol). Measurement techniques developed for toddlers may not be feasible for younginfants due to very small ear canals and the position of the child during the measurement. Thecurrent study examines a new measurement strategy for obtaining RECDs in infants 6 months ofage and younger. The procedure was tested on a clinical sample of infants. Measurements werecompleted twice on the same ear of each infant to obtain test-retest reliability data. In addition,probe tube insertion depth was examined across subjects to provide a guideline for the infantpopulation. The results of this study indicate that RECDs obtained using a new probe tubeinsertion strategy can be obtained reliably on infants aged 6 months and younger. A new strategyfor probe tube insertion depth will be described.

14

Copyright © 2005, Beaton, J.

The effectiveness of group therapy in improvingfunctional communication in adults with aphasia

Beaton, J.M.Cl.Sc. (SLP) Candidate


This critical review examines the effectiveness of group therapy in improving functionalcommunication among persons with aphasia. Study designs include: one group pretest- posttests, awithin-subjects design, and a randomized controlled trial. Overall, research supports that grouptherapy is found to improve functional communication skills in adults with aphasia; however,identification of one superior therapy in the treatment of persons with aphasia has not yetoccurred.

Introduction

Aphasia is described as “impairedcomprehension and production of language, usuallycaused by pathology affecting the language-competent half of the brain” (Brookshire, 2003, p.1).

For persons with aphasia, recovery is mostprofound within the first 6 months post injury and theinitial severity, lesion size, and time post onset arefound to be the best predictors of degree ofspontaneous recovery (Whitaker, 1998).Spontaneous recovery is the period after an injuryduring which some degree of recovery of impairedfunctioning is expected (Whitaker, 1998). Researchhas suggested mixed outcomes in efficacy studies forgroup therapy, although numerous studies havedemonstrated positive outcomes beyond the period ofspontaneous recovery (Aten & et al., 1982; Brumfitt& Sheeran, 1996; Elman & Berstein-Ellis, 1999;Marshall, 1993).

Although individual therapy is the traditionalapproach used for the treatment of patients withaphasia, it is often limited in facilitating the transferof skills to more natural settings (Elman & Bernstein-Ellis, 1999). It has recently been reported thatSpeech-Language Pathologists are looking in thedirection of therapy that is geared towards morefunctional communication gains for persons withaphasia (Brumfitt & Sheeran, 1997).

Treatment groups allow for a more naturalenvironment for communication for adults withaphasia compared to individual therapy, but arecontrolled and less threatening than day-to-day socialsituations (Brookshire, 2003). Group therapy is oftenused to complement individual therapy and is foundto provide the following gains over one-on-onetreatment: promoting the transfer of skills tofunctional communication, modeling ofcommunication by peers, and support (Marshall,1993). It may also increase the clients’ self-esteem,

encourage further involvement in the community, andit is cost-effective (Elman & Bernstein-Ellis, 1999).

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theimpact of group therapy on individuals with aphasia.The secondary objective is to propose evidence-basedpractice recommendations for future research.

Methods


PsychInfo, and PubMed, were searched using thefollowing search strategy:

((Aphasia) OR (adults with aphasia) OR(aphasics)) AND ((group therapy) OR(group treatment) OR (group program) OR(functional communication therapy)) AND(functional communication).


Selection Criteria Studies selected for inclusion in this criticalreview paper were required to investigate the impactof any type of group therapy program on thefunctional communication abilities among adults withaphasia. No limits were set on the demographics ofresearch participants.

Data CollectionDue to the limited scope of this assignment, only

a small set of articles were reviewed, although furtherresearch is available. Results of the literature searchyielded the following types of articles congruent withthe aforementioned selection criteria: one grouppretest-posttest (2), within-subjects design (1), and arandomized controlled trial (RCT) (1).

15

THE EFFECTIVENESS OF GROUP THERAPY IN IMPROVING FUNCTIONAL COMMUNICATION IN ADULTS WITH APHASIA

Results

Effectiveness of Group Therapy on FunctionalCommunication

Marshall (1993) indicated that 14 out of 25participants improved on the Porch Index ofCommunicative Abilities (PICA), showed goodparticipation, and were found to attend most sessions,while those who did not improve were at least fouryears post-stroke or dropped out of the study.

Aten, Caligiuri, & Holland (1982) comparedmean scores pre and post treatment on the PICA andthe Communicative Abilities of Daily Living(CADL) (Aten et al., 1982). A t-test analysis forrepeated measures was not found to be significant(Aten et al., 1982).

Few changes in means were noted on the PICAbetween pre and post treatment for the sevenparticipants (Aten et al., 1982). Improvements inmeans on the CADL at six weeks of therapy andpost-therapy compared to pretreatment, were found tobe significant, while the mean at six weeks post-treatment was similar to the mean at post-treatment(Aten et al., 1982). There was high variability inCADL scores from pre-treatment to six weeks posttreatment, therefore some participants had reducedscores but overall, the means showed improvements(Aten et al., 1982).

Brumfitt & Sheeran (1997) compared differencesbetween scores before and after treatment andreported statistically significant changes in functionalcommunication scores, particularly in the ‘speaking’domain of the Functional Communication Profile(FCP) (t = 2.54, p=0.03).

Elman & Bernstein-Ellis (1999) compared grouptherapy to a control group receiving no treatment anda treatment effect was found for scores on theWestern Aphasia Battery (WAB), the CADL, but noton the shortened PICA (SPICA) (p < .05). Greaterimprovements were noted for more severe patientswith fewer changes observed in milder patients(Elman & Bernstein-Ellis, 1999).

The scores on the WAB, the SPICA, and theCADL showed significant changes when comparingintake and pretreatment to 2 months of therapy, andthe WAB and the CADL for 2 months and 4 monthsof therapy (Elman & Bernstein-Ellis, 1999). Nosignificant changes were found at follow-ups (Elman& Bernstein-Ellis, 1999).

The results of this study demonstrated that grouptherapy is an efficacious treatment for functionalcommunication in adults with aphasia (Elman &Bernstein-Ellis, 1999).

Discussion

Sample SizeThe small sample sizes (ranging from 6 to 28) in

these studies may limit the generalizability of theresults to the population of adults with aphasia as awhole.

Measurement ToolsThe measurement tools used to assess functional

communication are the following: the CADL(Holland, 1980), the Communication EffectivenessInventory (CEI) (Lomas et al., 1989), the WAB(Shewan & Kertesz, 1980), the PICA (Porch, 1981),the shortened PICA (Elman & Bernstein-Ellis, 1999),and the FCP (Aten et al., 1982; Brumfitt & Sheeran,1997; Elman & Bernstein-Ellis, 1999; Marshall,1993). These tools have been shown to be reliableand valid, and with the exception of the WAB, theyhave been designed to assess functionalcommunication. Therefore, more confidence can beplaced in the results of these measurement tools.

Outcome MeasuresOutcome measures included: increases in

initiating conversation and exchanging information inwhatever means possible (Elman & Bernstein-Ellis,1999); improvements in communicative competence(Brumfitt & Sheeran, 1997); and improved scores onthe CADL (Aten et al., 1982), or the PICA (Marshall,1993). These measures do not satisfy all areas offunctional communication. To respond to thequestion, a more common definition of the constructof functional communication is required.

DesignOne group pretest-posttests (Aten et al, 1982;

Brumfitt & Sheeran, 1997), a within-subjects design(Marshall, 1993) and a randomized control trial(Elman & Bernstein-Ellis, 1999) were used. With theexception of the randomized control trial, the designsdo not show high internal validity and clinicianscannot be certain that the results are due to therapy.Also, it is difficult to generalize these results tonatural settings, indicating poor external validity.

Use of Mean DataBrumfitt and Sheeran (1997) addressed that one

difficulty with comparing mean scores is it maydisguise the number of subjects demonstrating actualimprovement. Therefore, the means of the results arepotentially inflating the positive outcome.

Controlling for ConfoundsElman and Bernstein-Ellis (1999) controlled for

social isolation in the control group. They also

16


controlled for both time and treatment by comparingchanges in scores in the Immediate Treatment groupwith those of the Delayed Treatment group (Elman &Bernstein-Ellis, 1999). Beyond the randomizedcontrol trial, the studies did not control for allconfounds (e.g., maturation, history, experimentalmortality, selection, etc.) which could be influencingthe accuracy of the results (Aten et al. 1982; Brumfitt& Sheeran, 1997; Marshall, 1999).

Conclusions

The research discussed demonstrates clinicalrelevance and in general, suggests that group therapyis effective in improving functional communicationin adults with aphasia. It is recommended that grouptherapy continue in practice by clinicians as it isfound to show only positive outcomes. In fact, grouptreatment has been shown to bring about significantimprovements in functional communicationcompared to controlled groups who received notreatment, including improvements shown 2 and 4months after completion of therapy (Elman &Bernstein-Ellis, 1999).

Few studies have determined who receives thegreatest benefits from group therapy based on theseverity of the aphasia. One study found greaterimprovements for individuals with severe aphasia(Aten et al., 1982) while Marshall (1993) showedprogress in clients with mild aphasia.

Research has shown that beginning therapyimmediately post-injury is ideal (Marshall, 1993). Itis reported that clients receiving delayed therapycould achieve similar effects, but would require alonger period of therapy (Elman & Bernstein-Ellis,1999). Even short-term therapy, compared to otherterms of group therapy, showed improvements in asfew as 10 sessions (Brumfitt & Sheeran, 1996). Atenet al. (1982) found maintenance of skills post-treatment although further research is required tosupport this.

Overall, the research is lacking some significantinformation. Therefore, it is recommended thatfurther research be considered when consideringpracticing group therapy over other treatmentoptions.

This review of the research suggests a need forfuture research in evaluating the effectiveness ofgroup therapy in improving functionalcommunication in adults with aphasia. Some futureconsiderations should include replication of therandomized control trial by Elman and Bernstein-Ellis (1999). The degree of gains of group therapycomparing short term versus long of term therapyshould be considered (Brumfitt & Sheeran, 1997). Acomparison between a treatment group and a control

group (e.g., the standard treatment such as individualtherapy or to other treatment options such ascomputer-based therapy) would determine whetherthe effects are due to the treatment, and evaluatewhich treatment methods are superior in improvingfunctional communication in adults with aphasia.The transfer and maintenance of learned functionalcommunication skills to more natural settings shouldbe evaluated (Marshall, 1993). The influence of theclient’s own perception of their role in increasingtheir functional communicative abilities should alsobe a focus of further research (Marshall, 1993).

Group therapy is an important treatment toconsider for persons with aphasia as it has multipleadvantages. Group therapy is cost-effective for boththe client and the Speech-Language Pathologistcompared to individual therapy (Marshall, 1993).Numerous reports by clients and family memberssupported improvements in positive attitudes andconfidence in clients, both during and post-treatment,even when communication may not have showndirect progress (Brumfitt & Sheeran, 1997; Elman &Bernstein-Ellis, 1999; Marshall, 1993).

While no evidence exists to identify onetreatment as superior, there appears to be support forgroup therapy at minimum as an adjunct to othertreatments in targeting functional communicationskills.

References

Aten, J., Caligiuri, M., & Holland, A. (1982). Theefficacy of functional communication therapy for

chronic aphasic patients. Journal of Speech and Hearing Disorders, 47, 93-96.Brookshire, R. (2003). Introduction to neurogenic

communication disorders. Missouri: Mosby Inc.Brumfitt, S., & Sheeran, P. (1996). An evaluation of

short-term group therapy for people withaphasia. Disability and Rehabilitation, 19(6),221-230.

Elman, R., & Bernstein-Ellis, E. (1999). The efficacyof group communication treatment in adults withchronic aphasia. Journal of Speech, Languageand Hearing Research, 42, 411-419.

Holland, A. (1980). Communicative abilities in dailyliving. Baltimore: University Park Press.

Lomas, J., Pickard, L., Bester, S., Elbard, H.,Finalayson, A., & Zoghaib, C. (1989). Thecommunicative effectiveness index:Development and psychometric evaluation of afunctional communication measure for adultaphasia. Journal of Speech and HearingDisorders, 54, 113-123.

17


Marshall, R. (1993). Problem-focused grouptreatment for clients with mild aphasia. AmericanJournal of Speech-Language

Pathology, 2(2), 31-37.Porch, B. (1981). Porch index of communicative

ability. Palo Alto, CA: Consulting Psychologists.Shewan, R., & Kertesz, L. (1980). Western Aphasia

Battery. Journal of speech and hearingdisorders, 308-324.

18

Copyright © 2005, Beaudin, P.G., Meltzner, G., Doyle, P.C., Hillman, R.E., Symons, S.L., & Reeves, A.

Evaluation of listener preference andintelligibility for a prototype electrolarynx

Beaudin, P.G., M.Sc.1,2, Meltzner, G., M.S.3, Doyle, P.C., Ph.D.1,2,Hillman, R.E., Ph.D.3, Symons, S.L., B.HSc.1, Reeves, A., B.HSc.1

1Voice Production and Perception Laboratory, The University of Western Ontario, London, Ontario2Doctoral Program in Rehabilitation Sciences, The University of Western Ontario, London, Ontario3Harvard-MIT Division of Health Science and Technology, Harvard Medical School, Boston, Massachusetts

This study investigated the auditory-perceptual (AP) evaluation of electrolaryngeal sentences.Fifteen naïve listeners provided preference and intelligibility judgments of sentences produced byfour laryngectomized speakers using a paired-comparison paradigm. Each speaker used aprototype electrolarynx (PEL) and a commercially available device (Servox). Results showed aclear preference for the PEL. Rehabilitation implications are discussed.

19

Copyright © 2005, Beaudin, P.G., Doyle, P.C., Eadie, T.L., & Reeves, A.

Psychophysical evaluation of pleasantnessand acceptability for electrolaryngeal speech

Beaudin, P.G., M.Sc.1,2, Doyle, P.C., Ph.D.1,2, Eadie, T.L., Ph.D.1,2,3, Reeves, A., B.HSc.1

1Voice Production and Perception Laboratory, The University of Western Ontario, London, Ontario2Doctoral Program in Rehabilitation Sciences, The University of Western Ontario, London, Ontario3Department of Speech & Hearing Sciences, University of Washington, Seattle, Washington

This presentation provides information on the psychophysical, auditory-perceptual (AP)characteristics of electrolaryngeal (EL) speech. Sentence stimuli produced using the Servox ELwere assessed by 12 naïve listeners for the perceptual features of pleasantness (PL) andacceptability (AC). Methodological concerns influencing psychophysical measurement and therelated clinical implications are discussed.

20

Copyright © 2005, Boucher, J.

The impact of PROMPT therapy on communication disorders

Boucher, J.M.Cl.Sc. (SLP) Candidate


This critical review examines the effects of PROMPT therapy among persons with communicationdisorders. All of the reviewed studies were identified as single subject, multiple baseline designs.The communication disorders examined in these studies included apraxia of speech andphonological delay. Based on this review, there is evidence to suggest that PROMPT therapy iseffective for treatment of apraxia in adult aphasics. There was no evidence that PROMPTtreatment was effective for children with developmental phonological disorders. The results of thepresent review should be interpreted with consideration of the inherent limitations of themethodology and statistical analysis used in the reviewed studies.

Introduction

The Prompts for Restructuring Oral andMuscular Phonetic Targets (PROMPT) system,introduced by Chumpelik (1984) and furtherdeveloped by Square-Storer and Hayden (1989), is atactile speech treatment approach that is based on thekinesthetic awareness of movement patterns(Hayden, 1984). The clinician places his/her handsand fingers on the client’s face and neck to givesensory feedback about the positions and places ofcontact of the speech mechanism required for specificspeech sounds (West, Hesketh, Bowen & Vail, 2004).Prompts are applied to the face to signal the facialmuscles to activate lip retractions and lip rounding, tothe mylohyoid to signal the height of the tongue andconstriction of the oral cavity, and to the mandible tosignal degree of jaw opening. The clinician alsoprompts the timing of movements between positionsand the amount of tension required for each position(Square, 1994). The client moves through PROMPTtherapy along a continuum of increasing linguisticdifficulty and progressively learns to control thespeech-motor system. (Hayden & Square,1994).

Objectives

The primary aim of this paper is to criticallyevaluate the existing literature regarding the impactof PROMPT therapy on communication disorders.The secondary objective is to provide an evidence-based recommendation about the application ofPROMPT therapy with particular client populationsin the clinical setting.

Methods

Search StrategyThe studies were found using a computerized

database search, including PubMed, Medline,PsychINFO, and Cochrane Library. The followingkey terms were used:

((language) OR (language delay) OR(language disorder) OR (phonology) OR(phonological delay) OR (phonologicaldisorder) OR (speech) OR (speech delay)OR (speech disorder) OR (articulation) OR(articulation delay) OR (articulationdisorder) OR (apraxia) OR (apraxia ofspeech) OR (apractic) OR (motor speech)OR (motor) OR (communication) OR(communication disorder) OR(communication delay) OR dysarthria))AND ((PROMPT) OR (PROMPT therapy)OR (PROMPT treatment))

The search was limited to articles written in theEnglish language.

Selection CriteriaStudies that were selected for inclusion in this

critical review paper examined the impact ofPROMPT therapy on any type of communicationdisorder. No restrictions related to subjectdemographics or outcome measures.

Data CollectionThe literature search yielded five articles that

employed multiple baseline, single subject design.

21

THE IMPACT OF PROMPT THERAPY ON COMMUNICATION DISORDERS

Results

Impact of PROMPT on Acquired Apraxia of Speechwith Aphasia

Four studies were found to support theconclusion that PROMPT can be an effectivetreatment for the speech difficulties experienced byclients with aphasia and acquired apraxia.

Square, Chumpelik, and Adams (1985) reportedthat one severely apraxic adult participant withmoderate Broca’s aphasia achieved 90-100%accuracy when producing phrases, similar successwith minimal word pairs and improved intelligibilityas measured by the Assessment of Intelligibility ofDysarthric Speech after participating in PROMPTtherapy. No improvements were attributed to anothertreatment: integral stimulation therapy.

Square, Chumpelik, Morningstar & Adams(1986) compared the PROMPT method to integralstimulation therapy in three adult participants withacquired apraxia of speech and Broca’s aphasia.They concluded that PROMPT was most effective inhelping these participants to accurately producefunctional utterances (98-100%), phoneme contraststhat were previously unmarked (i.e., 90-100%) andpolysyllabic words (75-100%).

Freed, Marshall, & Frazier (1997) found that aseverely apraxic-aphasic adult participant showedmaintained production of words and phrases (i.e.,78.2%) after receiving PROMPT treatment.

Most recently, Bose, Square, Schlosser, & vanLieshout, (2001) used PROMPT treatment with anadult participant with Broca’s aphasia and apraxia ofspeech. They found improved production ofimperative and active declarative sentences but not ofinterrogative sentences. Correct production when theparticipant used imperative forms was as high as 75%(mean 42%) and for active declarative forms ofsentences, production scores increased from 10% toas high as 55% (mean 49%). However, correctproduction of interrogative sentences remained atlevels similar to baseline scores (ie., 24%). This wasthe first attempt by researchers to investigate theeffectiveness of motor facilitation using PROMPTtherapy for improving control of speech movementsin utterances of varying complexity and differentsentence types.

Impact of PROMPT on Developmental PhonologicalDisorder

One study, by Dodd & Bradford (2000),investigated the efficacy of different therapy methodsfor three boys aged 3-5 years who had two types ofphonological disorders (i.e., consistent non-developmental phonological disorder andinconsistent phonological disorder). The therapy

methods examined were: 1) Metaphon therapy:Phonological based rules about the contrastive use ofphonemes were taught, 2) Core Vocabularyapproach: A small vocabulary of words was taughtwith consistency of production as the goal rather thancorrect production, 3) PROMPT. Based on TheGoldman-Fristoe Test of Articulation (Goldman andFristoe 1986), phonological analysis, spontaneousspeech samples, and the Test for AuditoryComprehension of Language – Revised (TALC-R)(Carrow-Woolfolk, 1985), The researchersdetermined that phonologically based Metaphontherapy was most successful for the child with theconsistent non-developmental phonological disorder.The Core Vocabulary approach was most efficaciousfor the two boys who had an inconsistentphonological disorder. None of the children showedany improvement as a result of PROMPT therapy.The researchers concluded that therapy involvinginformation about phonetic placement was not foundto be effective for children with phonological speechdisorders.

The studies in the present review were found tohave some methodological and statistical weaknesseswhen examined. For example, the Square et al(1995) publication was very brief and did not provideenough information for the reviewer to criticallyinvestigate its methodology or results in any way. Itwill not be considered in the following critique.

Single-subject designs allow the researcher toevaluate whether a behaviour change has occurredand analyse whether those changes happened inresponse to the treatment. Most commonly,researchers plot the data points on a graph andvisually analyse the results. It is also possible tostatistically analyse the data in order to gain a morequantitative perspective of the data. Of the fiveresearch-oriented articles published in the literature,none used statistical analysis. Real data can be sovariable that subjective determinations are oftenweak and unreliable. It is a concern that visualinferences may not be reliable enough to support allclinical decisions (Portney & Watkins,1993).

Mean values should always be shown on a graphof the raw data to reduce misinterpretation in thistype of design (Portney & Watkins, 1993). All of thestudies met this criterion except for Square, et al(1996); raw data was presented but was not plottedon a graph for visual analysis.

Baseline data should be stable or moving in atrend that is in a direction opposite to that expectedduring intervention before the intervention begins(Portney & Watkins, 1993). Square et al (1996) didnot report sufficient baseline data for the reviewer todetermine if this criterion was met. Freed et al(1997) conducted only one baseline probe before

22


PROMPT treatment began, and collected morebaseline data in a sequence throughout the treatmentphase of the study. It is not possible to determine theparticipant’s true baseline performance under theseconditions. All other researchers were considered tohave collected appropriate baseline measures.

Dodd & Bradford (2000), Square et al (1996),and Freed et al (2001) reported interrater reliabilityusing point-to-point reliability. This measure isadequate for use in single subject designs. However,by using the occurrence/nonoccurence reliabilitymeasure or by assessing chance agreement using thekappa statistic, the researchers would have found amore reliable measure of interrater agreement. Boseet al (2001) reported mean interobserver percentagreement, which is the least reliable interraterreliability measure available (Portney & Watkins,1993).

Single subject designs are limited in theirexternal validity. It is difficult to generalize theresults of these kinds of studies beyond the behaviourof the single individual. The only way todemonstrate external validity in single subjectresearch is by way of replication using other similarsubjects in different settings (Portney & Watkins,1993). The reviewer found that the literature waslacking in this area. More research needs to be doneand published on the topic of PROMPT to increaseits external validity.

PROMPT Therapy and Clinical Populations.Based on the literature reviewed, it appears that a

recommendation for the application of PROMPTtherapy for use with adult aphasic clients to treatacquired apraxia is warranted. Further research onthis topic, which improves on the methodological andstatistical weaknesses of past studies, may provideclinicians with greater confidence in this proposal.

The review did not justify a recommendation forthe use of PROMPT therapy with children withdevelopmental phonological disorders. Dodd &Bradford (2000) argued that it is doubtful that atherapy method that focused on the motoricproduction of speech sounds (i.e., PROMPT) wouldhave a significant influence on the speech of childrenwith phonological disorders because it does notafford phonological information; such as thecontrastive features of phonemes. This positionshould be received with the awareness that it is basedon only one study and that future research may ormay not concur.

Conclusions

The present review is of benefit to the clinicalSpeech Language Pathologist who intends to gain a

better understand of the efficacy of PROMPT therapyand the populations appropriate for its application.

It seems that PROMPT has been effective fortreatment of communication disorders involvingmotoric elements such as the execution of motormovements and motor planning (i.e., acquiredapraxia of speech). Perhaps other communicationdisorders having a possible motoric component canbe effectively treated with PROMPT. Futureresearch involving the application of PROMPT fortreating communication disorders such as dysarthria,articulation disorder or dysfluency may prove to beremarkable.

Future research should strive to include optimalmethodological design and robust statistical analysis.Statistical analysis such as serial dependency and thetest of significance using the split-middle techniqueare suggested. It is also important, especially insingle subject design, that enough methodologicaland measurement information be presented inpublications so that other researchers may replicatestudies in order to increase the validity ofconclusions. (Portney & Watkins, 1993).

References

Bose, A., Square, P.A., Schlosser, R., and vanLieshout, P. (2001). Effects of PROMPTtherapyon speech motor function in a personwith aphasia and apraxia of speech.Aphasiology,15(8), (pp. 767-785)

Carrow-Woololk, E. (1985). Test for AuditoryComprehension of Language – Revised.

Chumpelik (Hayden), D. (1984). The PROMPTsystem of therapy: Theoretical Framework andapplications for developmental apraxia ofspeech. Seminars in Speech and Language, 5,(pp., 139-156).

Dodd, B., & Bradford, A. (2000). A comparison ofthree therapy methods for children with differenttypes of developmental phonological disorder.

Freed, D.B., Marshall, R.C., and Frazier, K.E. (1997).Long term effectiveness of PROMPT treatmentin a severely apractic-aphasic speaker.Aphasiology, 11, (pp.365-372).

Goldman, R. & Fristoe, M. (1986). Goldman-FristoeTest of Articulation.

Hayden, D.A., & Square, P.A. (1994). Motor speechtreatment hierarchy: A systems approach.Clinics in Communication Disorders, 4(3), (pp.,162-174).

Portney, L. & Watkins, M. (1993). Foundations ofClinical Research: Applications to Practice.Appleton and Lange, Connecticut, U.S.A.

23


Square, P.A. (1994). Treatment approaches fordevelopmental apraxia of speech. Clinics inCommunication Disorders, 4(3), (pp. 151-161).

Square, P.A., Chumpelik, D., and Adams, S. (1985).Effects of the prompt system of therapy for thetreatment of acquired apraxia of speech. In R.Brookshire (E.d.). Clinical AphasiologyConference Proceedings, (pp., 319-320).

Square-Storer, P.A. & Hayden, D. (1989). PROMPTtreatment. In P.A. Square-Storer (Ed.).Acquired Apraxia of Speech in Adult Aphasics(pp., 190-219).

Square, P.A., Chumpelik, D., Morningstar, D., andAdams, S. (1986). Effects of the prompt systemof therapy for the treatment of acquired apraxiaof speech: a follow up investigation. In R.Brookshire (Ed.). Clinical AphasiologyConference Proceedings, (pp. 221-226).

West, C, Hesketh, A., Bowen, A., & Vail, A. (2004)Interventions for apraxia of speech following astroke (Protocol for a Cochrane Review). In TheCochrane Library, 3.

24

Copyright © 2005, Cameron, M.S.

The efficacy of acute stroke dysphagia therapy

Cameron, M. S.M.Cl.Sc. (SLP) Candidate


This critical review examines the efficacy of post-stroke dysphagia therapy through analysis ofpreviously conducted research studies. Study designs included: one-group repeated measures,randomized controlled trial (RCT), quasi-experimental design, nested design, and a one-groupinterrupted time-series analysis. Unfortunately, there is little consensus in the literature regardingthe effectiveness of intensive swallowing intervention; evidence directly addressing this issue islacking and inconclusive. Further research into the area of stroke rehabilitation, specificallydysphagia management and the amount and types of training needed must be explored.

Introduction

Stroke is a common and continuing problemwith an annual incidence of affecting 2-4 per 1000 ina given population (Perry & McLaren 2003). As aresult, stroke rehabilitation is becoming aconsiderable area for research involvement; acutestroke programs and clinical care pathways are beingimplemented in hospitals that include multi-disciplinary teams, “yet the potential of rehabilitationremains only partially realized” (Teasell et al. 2003).

Stroke is one of the most common causes ofneurogenic dysphagia. Determined by the timing ofassessment and the criteria used to diagnosedysphagia, the incidence fluctuates with most of theavailable data estimating swallowing abnormalities inapproximately 30-65% of stroke survivors.Currently, there are no standard North Americanguidelines for stroke rehabilitation or dysphagiamanagement; techniques vary across medicalfacilities.

Difficulties in deglutition can lead to subsequentdisabling factors such as aspiration, airwayobstruction, malnutrition, dehydration, pneumonia, orin some cases death. Thus, the high incidence ofdysphagia in acute stroke when paired with itspotential for life-threatening consequences makesidentification of these patients, as well as theapplication of management strategies for assuming asafe oral intake, pertinent.

The management of neurogenic dysphagiaconsists of many techniques, including directtherapies, such as compensatory strategies (posturaladjustments, diet modifications), and indirecttherapies, such as oral-motor exercises and thermal-tactile stimulation. The primary goals of therapy areto establish optimal nutritional status and reduce oreliminate the risk of developing confounding medicalcomplications. Unfortunately the efficiency of usingtraining strategies has not been comprehensivelyexplored (Lin et al. 2003).

Objectives

The primary objective of this review is tocritically evaluate the current literature regarding theefficacy of dysphagia therapy following acute stroke.The secondary objective is to propose an evidence-based practice recommendation about theimplementation of algorithms designed to guide andenhance rehabilitative therapy for the stroke survivor.Such an increase in quality of care will be evaluatedin its potential to subsequently decrease inpatientlength of stay (LOS) and overall health care costs.

Methods

Search StrategyA search limited to articles written in English

and between the years of 1990 and 2004 wasconducted using computerized databases, includingPubMed and CINAHL.

Selection CriteriaStudies included in this critical review were

required to investigate the impact dysphagia therapyhas on patient prognosis or the impact that thepresence of dysphagia alone has on overall prognosis.

Data CollectionResults of the limited search produced the

following study designs in congruence with thechosen selection criteria: one-group repeatedmeasures (2), randomized controlled trial (RCT) (1),quasi-experimental design (1), nested design (1), andone group time series analysis (1).

Results

DesignThe six articles included in this review each

addressed one of two questions associated with theefficacy of swallowing therapy. Four of the articles(DePippo et al. 1994, Lin et al. 2003, Elmstahl et al.1999, Runions et al. 2004) asked whether swallowing

25

THE EFFICACY OF ACUTE STROKE DYSPHAGIA THERAPY

therapy programs alter the prognosis of strokepatients and one article (Finestone et al. 2002) askedwhether the presence of post-stroke dysphagia altersthe prognosis of stroke patients. The Odderson et al.(1995) study applied a nested research design toaddress both variables.

A prospective and longitudinal study design wasemployed in all six studies. In addition, all werelarge scale designs with sample size varying innumber from 30-124 participants. Overall, there washomogeneity of subjects both within and acrossstudies. The average subject was male, in hisseventies suffering a hemispheric stroke with anischemic etiology. This description matches thenorm as stroke affects more men than women andoften occurs in the 7th decade of life. As well, anischemic stroke is a more common etiology thanhemorrhagic. Since each study used conveniencesampling based in the hospital setting, the averagestroke patient was validly represented.

Supportive Evidence

Impact of Dysphagia Therapy on Length of Stay“Research has indicated that implementing

clinical guidelines and algorithms improvesdysphagia management and patient outcomes”(Runions 2004).

Four months after the implementation of adietary management algorithm, descriptivecomparisons from 30 medical records were reviewedby Runions et al., to assess the appropriateness ofdysphagia management as part of a clinical pathway.Both nonparametric and descriptive statistics wereused and it was found that patients with dysphagiawere hospitalized more than 2.5 times longer thannon-dysphagic patients. The differences in dischargedispositions between the two groups were also notedto be statistically significant (p<0.01). Overall,70.6% of patients improved swallowing functionduring hospital admission after being placed on analgorithm. Thus, the use of an algorithm wasconcluded to decrease the risk of complications,decrease LOS, and facilitate timeliness of totalintervention (decrease in health care costs).

Although this paper was reader friendly and thefindings were displayed in a straightforward fashion,unfortunately it had poor construct validity since itfailed to measure what it purported; it did notprimarily assess the effectiveness of an algorithm.The algorithm was not compared to any other data;there was no use of a control group or retrospectivedata from years prior to implementation. As such,maturation bias was not controlled for and it istherefore difficult to parse out what was a result of

the swallowing protocol versus what would naturallyhappen in any hospitalized patient.

In a similar study Odderson et al. alsoevaluated a clinical pathway; however its designvalidated the results more than the previous study. Itutilized a nested design that retrospectively evaluatedone-group using repeated measures over 3 differenttime periods (pathway year, pre-pathway year andyear prior to pathway), while prospectivelycomparing dysphagic patients versus non-dysphagicpatients along a number of variables.

The dysphagic patients (38.7% of 124 subjects)had longer LOS (2.0 days longer, p= .05), and wereless likely to be discharged to the community.Overall outcome disposition was significant (p<0.05)between the two groups, where patients withoutdysphagia were likely to be discharged to thecommunity and patients with dysphagia were twiceas likely to be discharged to a nursing home.

Dysphagia management was deemed animportant part of acute stroke intervention since itwas expected to result in fewer complications anddecreased medical costs, while assuring quality ofcare and optimal outcomes for the patients.

Overall this study was easy to follow and theresults were made clear by the data collected;furthermore, these findings were well accounted foras appropriate parametric tests were incorporated intothis large scale study (inherently more powerful).

Impact of Dysphagia Therapy on PrognosisDysphagia training programs are also noted to

improve swallowing function and nutritional status.The remaining studies focused on the physiologicalimpact that dysphagia therapy has on stroke (whichaffects overall prognosis). For instance, Elmstahl etal. used videofluoroscopy (VBSE) as well asmeasures of nutritional variables on the same groupof subjects at baseline and again after 2 months ofswallowing therapy (direct and indirect). Thefindings from this study were interpreted to indicatean association between dysphagia treatment andimproved nutritional outcomes in 60% of strokepatients. Swallowing functions improved aftertherapy and the overall VBSE score was reducedfrom 13.5 to 9.9 after treatment (p<0.01). However,it should be noted that there is a potential attritionbias present in this study since the data was assessedusing an ‘on-protocol’ analysis where groups areanalyzed where they end up causing the 20% of thesample lost throughout the study to be unaccountedfor.

In a double-blinded quasi-experimental study,Lin et al. also confirmed the efficacy of aninterdisciplinary training program in improvingswallowing function and nutritional status of stroke

26


residents. Seven hospitals were allocated to havepatients be involved as either control subjectsreceiving no therapy over the eight weeks of thestudy, or experimental subjects receiving 30 minutesof swallowing therapy a day for 8 weeks.

This study revealed an improvement inswallowing function and speed, an increased bodyweight, and a decrease in coughing in those patientswho received dysphagia management. It is aneffective study with a strong design for testing theefficacy of swallowing therapy and valid applicationof nonparametric statistical tools; conversely, itwould never be replicated in western countries wherea ‘no therapy’ control group is deemed unethical.Study limitations were identified and it was pointedout that individual differences in residents were notconsidered and so some of the participants may havereceived more training than necessary (which wouldnot be cost-effective).

Opposing Evidence

Standard of Care & Spontaneous RecoveryIn addition to the previous intervention studies,

the DePippo et al. study measured the efficacy ofswallowing therapy using a randomized control trial(RCT). A ‘standard-of-care’ control group wascompared to 2 other groups of subjects receivinggraded levels of dysphagia therapy using pathological“study endpoints” as outcome measures. Log rankstatistics were used to compare all three groups and itwas concluded that some swallowing therapy isnecessary; however since there were no significantdifferences between the 3 groups, intensive therapymay not be appropriate. Only 15% of patientsdeveloped any of the 5 target medical complications(endpoints) during their inpatient stay. However, thesmall number may be due to all patients havingreceived some level of treatment.

Although this study applied the best design (a“gold-standard” RCT), the chosen outcome measureswere a definite area of weakness. The dependentvariables were all pathological in nature and perhapsadditional measures such as qualitative or clinicalmeasures (LOS, subjective reports, bodycomposition, etc.) should have been included.

Finally, Finestone et al. used a one-grouprepeated measures design to observe the progressionof a single group compared over time. This studywas unlike the rest as it attempted to define naturalrecovery of swallowing without intervention. Thenatural history of swallowing recovery was analyzedon admission, at days 21 and 90. The dependentvariables were dysphagia (based on diet type),dysphagia recovery (determined by an upgrading ofthe diet), and the presence of pneumonia as a

complication of stroke. There were no statisticalmeasures reported as this was a purely descriptivereport. However, this is not necessarily a weaknessof the study since a descriptive design is expectedwhen observing a process such as natural recovery.The findings from this study indicate that 75% ofpatients will consume their pre-stroke diet by 3months; therefore therapy is viewed as unnecessary.

Overall, the DePippo et al. study had the bestdesign for addressing the issue of swallowingtherapy, but the best outcome measures wereincluded in both the Odderson et al. and Runions etal. studies which used outcome measures both interms of pathological data, clinical, and qualitativedata (LOS, outcome disposition, functionalindependence scores). The most productive studybased on design as well as outcome measures was theLin et al. quasi-experimental design, but it isunethical to replicate such a study.

Recommendations

Current literature providing evidence pertainingto the efficacy of dysphagia management is lacking.Four of the six articles reviewed were in support ofextensive swallowing therapy and two were in slightopposition. However, none of the articles offereddata sufficient to issue recommendations.

In the supportive evidence collected, the generalrecommendation appears to be that a standardswallow screen should be performed within 72 hourspost-stroke. The information obtained from thisinitial screening should then be used to place thepatient on a specific care pathway, includingextensive dysphagia management as required.Swallowing therapy is collectively deemed a crucialpart of stroke intervention since it is noted todecrease complications and improve speed ofswallowing function. Increased quality of care isbelieved to benefit the general well being of patientsand also result in a subsequent decrease in LOS andhospital costs.

However, the suggestion of all patients receivingswallowing therapy must be interpreted with caution.Individualized intervention is crucial; uniquedifferences in residences must be applied to careprotocol since some patients may end up receivingmore training than necessary which is no longer costeffective.

The opposing articles claim that the recovery ofswallowing function occurs regardless of thepresence or degree of therapy. However, thesearticles do not provide glaring evidence upon whichto base conclusions. In both studies, the patients mayhave recovered naturally or with standard careaccording to physiological measures, but other

27


important factors such as LOS or quality of life issueswere not taken into consideration. Conceivably,patients will eventually recover without therapy, butwith additional management of swallowing they mayrecover at a more rapid rate making it a cost effectiveendeavor in the long-term. A worthwhileundertaking would be for these studies to take theirinquiries a step further so to include LOS and cost ofcare as additional outcome measures.

Conclusions

On the whole, the literature reviewed did notprovide strong enough evidence in support of post-stroke intensive dysphagia management; however, itdid provide insight as to how to go about furtherresearching this crucial area. Perhaps the best way todetermine the efficacy of swallowing therapy wouldbe to apply a RCT design with outcome measuresthat make pathological as well as qualitative andclinical observations upon which to base conclusions.Additional studies of this magnitude are necessary toidentify the effectiveness of various types andamounts of swallowing therapy for the strokepopulation.

Furthermore, despite the lack of overwhelmingevidence in favour of post-stroke dysphagiamanagement, there is sufficient support available inthe selected literature to warrant further explorationof post-stroke algorithms that include dysphagiatherapy as part of a rehabilitation protocol. Forinstance, within the current literature there is a notedand growing interest in the area of cost reductionwithin the health care sector. One of the proposalsfound in the research aiming to decrease costs is theimplementation of care pathways that add structure topatient care and reduce the overall length of inpatientstay, thereby reducing costs. Two of the studiesdirectly addressed this idea and by implementing apost-stroke algorithm they discovered a decrease inpatient LOS by an average of 2.25 days. Althoughthis may not seem like a significant reduction, anexample may help clarify the potential this may haveon individual hospitals: at London Health SciencesCenter in London Ontario, the average stroke patientremains in the hospital for approximately 11 dayswith a full estimated cost of $10,697. This total,minus the one-time expense for ECG and CT ($167& $268 respectively) can be divided by the amount ofdays spent in the hospital and gives an estimatedaverage daily cost of roughly $932 dollars per dayper patient (www.lhsc.on.ca/casecost/quality.htm).Thus, if only 5% of patients benefited from therapy,the hospital saves close to $10,000. This provides anexample of a single hospital using only five patientssent home two days early; the implications this could

have on a decreasing health care costs can be inferredas quite substantial.

Ultimately guidelines should be implementedincluding a dysphagia management decision-makingprocess to provide the highest quality care for acutestroke patients.

References

DePippo K.L., Holas M.A., Reding M.J., MandelF.S., Lesser M.L. (1994). DysphagiaTherapy following stroke: a controlled trial.Neurology, Sept;44(9), 1655-60.

Elmstahl, S., Bulow M., Ekberg O., Petersson M.,Tegner H. (1999). Treatment of dysphagiaimproves nutritional conditions in strokepatients. Dysphagia 14, 61-66.

Finestone H.M., Woodbury M.G., Foley N.C.,Teasell R.W., Greene-Finestone L.S. (2002).Tracking clinical improvement ofswallowing disorders after stroke. Journalof Stroke and Cerebrovascular Diseases,11(1), 23-27.

Lin L.C., Wang S.C., Chen S.H., Wang T.G., ChenM.Y., Wu S.C. (2003). Efficacy ofswallowing training for residents followingstroke. Journal of Advanced Nursing,Dec;44(5), 469-78.

Odderson I.R., Keaton J.C., McKenna B.S. (1995).Swallow management in patients on anacute stroke pathway: quality is costeffective. Archives of Physical Medicineand Rehabilitation, Dec;76(12), 1130-3.

Perry L. & McLaren S. (2003). Eating difficultiesafter stroke. Journal of Advanced Nursing,43(4), 360-369.

Runions S., Rodrigue N., White C. (2004). Practiceon an acute stroke unit afterimplementation of a decision-makingalgorithm for dietary management ofdysphagia. Journal of NeuroscienceNursing, 36(4), 200-207.

Teasell R., Foley N., Bhogal S.K., Jutai J., SpeechleyM. (2003). Evidence-based review of strokerehabilitation: prepared for the Ministry ofHealth & Long-Term Care and The Heartand Stroke Foundation of Ontario.

28

Copyright © 2005, Cowan, S.L.

The impact of subjective thickening methods on individuals with dysphagia

Cowan, S. LM.Cl.Sc. (SLP) Candidate


This critical review examines the effects of subjective thickening methods on fluids for individualswith dysphagia. The studies were either experimental or quasi-experimental, with many of thememploying either a repeated measures design or a factorial design. Overall, the majority of theresearch supports the use of more objective measures for thickening liquids. Specifically, the useof a viscometer or rheometer as an objective tool for thickening liquids was suggested.Alternative suggestions were also provided by some researchers. A cost-benefit analysis needs tobe conducted to determine the most effective and feasible recommendations.

Introduction

A c c o r d i n g t o Logemann (1998)videofluoroscopy is the most common method ofassessment for the oropharyngeal swallow. It allowsone to visualize the movement of a bolus throughoutthe swallow to assess which consistency of foodand/or liquid is deemed the safest for the patient toconsume. If the patient is given an unsafeconsistency, he/she is at an increased risk foraspiration, and subsequently aspiration pneumonia orother medical complications. During thevideofluoroscopic examination, the speech languagepathologist (or other team member) prepares the foodand/or liquid in a variety of consistencies addingbarium to allow for observation on an x-ray. Thesamples are typically prepared subjectively, usingvisualization to determine when the product hasreached the appropriate consistency.

According to Glassburn and Deem (1998),although clinicians may follow the thickeningproduct’s directions carefully, there are still extensivediscrepancies in the amount of product that isrequired to attain a precise consistency. If theconsistency achieved were deemed safe for thepatient to ingest, due to the unregulated amount ofthickener used, it would be difficult to replicate theconsistency for the patient’s mealtimes. If thevideofluoroscopic liquids and mealtime liquids werenot identical in viscosity the patient is at an increasedrisk for aspirating the material. One potential avenuefor exploration is the use of objective measures forincreasing the consistency for thickening liquids.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theimpact of subjective thickening methods onindividuals with dysphagia. The secondary objectiveis to propose evidence-based practice

recommendations about specific types of objectivethickening methods as well as areas for futureresearch.

Methods

Search StrategyComputerized databases, including PubMed, and

EBM Reviews, were searched using the followingsearch strategy: ((Dysphagia) OR (Swallowingdisorder)) AND (thickening) AND (viscosity) AND(objective) AND (subjective) AND ((rheology) OR(rheological))

Selection CriteriaThe search was limited to articles written in

English between 1992 and 2004. Studies selected forinclusion in this critical review paper were requiredto investigate the impact of thickening methodsand/or types of thickening products on the overallviscosity of a liquid. No limits were set on thedemographics of research participants or outcomemeasures.

Research DesignThe studies examined were either experimental

or quasi-experimental, with many of the studiesemploying either a repeated measures design or afactorial design. The studies utilized a moderatesample size ranging from 23 to 66 subjects. Clustersampling was the most frequently employedsampling method, however in some studiesconvenience sampling and purposive sampling wereused. The subject demographics appear to be lackingsufficient detail in the majority of the studies andwere completely absent from others. Each studyincluded a range of one to three outcome measures,and they were both qualitative (ie- 3-point ordinalscale) and quantitative (ie- density, yield stress,viscosity) in nature. Overall, it appears that theoverall validity of this subset of the literature is

29

THE IMPACT OF SUBJECTIVE THICKENING METHODS ON INDIVIDUALS WITH DYSPHAGIA

adequate. Increased outcome measures andinformation regarding patient demographics may helpto increase the validity further.

Results

It was evident that the studies generally usedappropriate tests and procedures for the analysis oftheir data. The studies utilized a combination ofparametric and non-parametric tests for their dataanalysis, focusing on the association and interactionof the variables.

Evidence Supporting the Need for ObjectiveMeasurements

Overall, the majority of the researchers providedevidence to support the need for more objectivemeasures for preparing thickened liquids. Glassburnand Deem (1998) and Cichero, Jackson, Halley andMurdoch (2000) established that there was a negativecorrelation between thickened liquids used forvideofluoroscopic and mealtime purposes. It wasdetermined, following a replication reliabilityanalysis, that intrasubject reliability both within thesame hospital as well as across hospital settings waspoor. Although intersubject reliability was relativelybetter, there was still a large degree of variability inthe resulting consistencies of the products.

Goulding and Bakheit (2000) found that themean viscosity of the fluids in the control group(subjectively thickened liquids) was significantlyhigher than that of the study group (objectivelythickened liquids). Thus the accuracy of thesubjectively thickened liquids was unreliable.Reliability was found to increase when a viscometerwas utilized.

The aforementioned studies all agreed that usingobjective measures were necessary to increase thereliability of thickening liquids. Specifically, theyreferred to using either a viscometer or rheometer asan objective tool for measuring various aspects of theproducts consistency. Mann and Wong (1996) alsorecognized the need for more objective measures formixing liquids, however they suggested using theline-spread test as a cost-effective means forobjectifying the process. Following a two-wayanalysis of variance they found significantdifferences between judges’ subjective perceptions ofvarious thickened liquids. However, when the line-spread test was employed, it was found that thismethod demonstrated a high degree of predictivevalidity, and was thus an effective tool for objectivelythickening liquids.

Evidence Supporting Other Areas for InterventionAlthough the majority of the examined literature

produced data that favors more objective means forthickening liquids, select articles provided othersuggestions for evaluation to make thickening liquidsmore consistent. Steel, Van Lieshout and Goff(2003) reported that objective means for thickeningliquids were not completely necessary. They foundsignificant correlations between clinicians’ subjectiverankings and the independent variables of viscosity,yield stress and density. Therefore, when adequatesubjective means are utilized, liquids can bethickened to accurate consistencies.

Pelletier (1997) found significant two-way andthree-way interactions following completion of botha one-way ANOVA and a multifactor ANOVA. Thissuggested that the effect of the thickeners onconsistency of the product is based on thecombination of time, type of liquid being thickenedand the desired thickness of the product. Thus,variations in product consistencies may be present.Development of precise recipes for each type ofliquid and each brand of thickener may be required todecrease the variability of the thickened products.

Recommendations for Future Research

The purpose of placing an individual on amodified diet is to provide him/her with aconsistency that is safe for him/her to swallow and toreduce the risk of aspirating the material. Uponexamination of the literature it is evident thatreliability of the consistencies is variable when doneusing subjective methods, however the majority ofthe studies did not look at the effect of the bolusinconsistencies on the actual patient. Therefore,future studies should focus on determining the effectsthat small changes in the consistency of the liquidwould have on the patient. Studies of this naturewould allow one to determine if spending valuableresources on such tools as a viscometer or rheometerwould in fact reduce incidences of aspirationpneumonia and subsequently overall health carecosts.

Finally, when conducting research studies it isvital that the findings can be generalized to ‘real-life’settings. In much of the literature that was examined,the testing was done when the products were at the‘optimal temperature’. Although this gives us anaccurate indication of how the products function inan ideal situation this is not necessarily realistic to thehospital setting. Depending on when the patientreceives his/her meal, the temperature may vary frombeing the ‘optimal temperature’ to being closer toroom temperature. The changes in temperature mayaffect the consistency of the product and thus

30


increase the variability from meal to meal. It isimportant for future research to examine the effect oftime and temperature on the consistency of theproduct.

Recommendations for Clinical Application

The literature examined provided a lot ofinformation that is directly related to clinical practice.First of all, the evidence from the majority of thestudies indicated that more objective means arenecessary for thickening liquids. By using subjectivemethods there were a lot of inconsistencies withintrasubject reliability, and even more vital, withintersubject reliability. Many of the studies indicatedthat using a viscometer and/or a rheometer greatlyincreased the reliability of the thickening method. Assuch, one must consider whether the cost of thesolution outweighs the risks associated withsubjective thickening methods. The potential costsassociated with the inconsistent thickening of liquidsmay be far greater than the costs of a viscometer orrheometer. If a person begins to aspirate due toreceiving a consistency that was not deemed safe, theindividual may develop aspiration pneumonia.Medical costs associated with this illness (ie-increased length of stay in the hospital, blood work,swallowing assessments, modified barium swallowstudies etc.) will likely far surpass the cost of theviscometer. Thus, even though the initial cost ofpurchasing a viscometer appears to be considerable,the long-term implications could be immense.

The use of prethickened products should also beconsidered in reducing variability associated withthickening liquids. Although this is a costlyalternative, it ensures that products of reliableconsistencies are being given to the patients. Inaddition, this would reduce preparation time forassessments and meals, allowing the clinicians toattend to more patients. A cost-benefit analysisshould be completed to determine if this is in fact afeasible alternative.

Lastly, in the majority of the studies the speechlanguage pathologists were responsible for mixingthe liquids used for swallowing assessments.However, when a patient is in the hospital it is oftenthe kitchen staff that is preparing the trays formealtime purposes. As was previously mentioned,intra-clinician reliability is poor, and as such, one canpresume that the reliability between the productsproduced by the kitchen staff and clinicians is equallypoor. In order to minimize opportunities fordiscrepancies in bolus consistencies betweenassessment and mealtime fluids, having the kitchenstaff prepare all fluids may be a viable option. It isrecommended that a select group (that represents

individuals from each shift) be trained on how toaccurately thicken liquids, and they will become the‘specialists’ and the only individuals qualified tothicken the liquids. Although this will not eliminatethe variability in consistencies, hopefully it will serveto decrease the inconsistency of the thickenedproducts.

Conclusions

Upon examination of the results of the studies, itis evident that future research in the area ofthickening liquids is necessary to continue to build onthe aforementioned conclusions and fill in any gapsin the research. In particular, the effect of smallchanges in fluid consistency on individuals withdysphagia has not been established. This is importantinformation if one is going to propose the need forfunding for more objective tools to thicken liquids.In addition, to ensure the quality of the product doesnot fluctuate, research examining how time andtemperature effect consistency is vital.

Given the overwhelming support from theliterature that viscometers and/or rheometers shouldbe used to thicken liquids, it is evident that objectivemeans for thickening liquids should be adopted in theclinical setting. Additional methods of ensuringreliability of the products, such as using prethickenedliquids and/or making certain that employees aretrained appropriately may increase the uniformity ofthickened liquids, however cost-benefit analyses needto be performed to determine the most feasibleoptions.

References

Cichero J, Jackson O, Halley P, Murdoch B. (2000)How thick is thick? Multicenter Study of theRheological and Material PropertyCharacteristics of Mealtime Fluids andVideofluoroscopy Fluids. Dysphagia, 15, 188-200.

Cichero J, Jackson O, Halley P, Murdoch B. (2000)Which one of these is not like the others? Aninter-hospital study of the viscosity of thickenedfluids. Journal of Speech, Language, andHearing Research, 43, 537-547.

Glassburn D, Deem J. (1998). Thickener Viscosity inDysphagia Management: Variability amongSpeech Language Pathologists. Dysphagia, 13,218-222.

Goulding R. (2000). Evaluation of the benefits ofmonitoring fluid thickness in the dietarymanagement of dysphagic stroke patients.Clinicial Rehabilitation, 14, 119-124.

31


Logemann J (1998): Evaluation and Treatment ofSwallowing Disorders. Austin, TX: Pro-ed Inc.

Mann L, Wong K. (1996). Development of anobjective method for assessing viscosity offormulated foods and beverages for dysphagicdiet. Journal of the American DieteticAssociation, 96, 585-588.

Pelletier C. (1997). A Comparison of Consistencyand Taste of Five Commercial Thickeners.Dysphagia, 12, 74-78.

Stanek K, Hensley C, Van Riper C. (1992). Factorsaffecting use of food and commercial agents tothicken liquids for individuals with swallowingdisorders. Journal of the American DieteticAssoication, 92(4), 488-490.

Steele C, Van Lieshout P, Goff H. (2003). TheRheology of Liquids: A Comparison ofClinicians’ Subjective Impressions andObjective Measurement. Dysphagia, 18, 182-185.

32

Copyright © 2005, D’Cunha, B.

Effectiveness of intervention methods for those diagnosed with auditoryneuropathy/auditory dys-synchrony

D’Cunha, B.M.Cl.Sc. (Aud) Candidate


This critical review examines the effectiveness of hearing aids and cochlear implants on thosediagnosed with auditory neuropathy/ auditory dys-synchrony. Study designs include: longitudinalstudies, clinical and case studies. Overall, research supports the effectiveness of hearing aids andcochlear implants on some individuals with AN/AD. However, due to complexity of disorder andlarge individual differences in habilitation, individualized treatment plans are highlyrecommended.

Introduction

Auditory Neuropathy (AN)/Auditory Dys-synchrony (AD) is a form of hearing impairmentwhere outer hair cell function is intact, howeverafferent neural transmission is disordered (Rance et.al, 2002). Sininger 2002 estimates that AN/ADoccurs in about 1 in 10 children who have hearingloss and severely abnormal ABR. Evidence of outerhair cells is shown through the presence ofotoacoustic emissions (OAE) and/ or cochlearmicrophonics. The synchrony disorder is thenindicated through the absence of neural activity at theauditory nerve through an abnormal auditorybrainstem response result (Rance et. al, 2002).

Patients with AN/AD can have any degree ofhearing loss, however many present a severe toprofound loss (Sininger & Oba, 2001). Speechperception for those diagnosed with AN/ADprelingually varies considerably between patients(Rance et. al, 1999). Speech perception scores canbe out of proportion to the degree of loss measuredbehaviorally (Sininger et. al, 2001).

It is fairly easy to predict speech perception andauditory capabilities from an individual diagnosedwith a sensorineural hearing loss. This in turnallows for appropriate early intervention strategies tobe implemented (Rance et. al, 2002). Thisintervention plan is prescribed with reasonableconfidence based on the behavioral data from theaudiogram. Early findings fail to show thiscorrelation for those diagnosed with AN/AD (Ranceet. al, 2002).

Due to this difference in hearing impairment,intervention strategies and their effectiveness are ofquestion. Hearing aids and cochlear implants are twomethods of intervention that provide benefit for onlysome individuals with AN/AD. Due to thecomplexity of the disorder and relatively newdiagnosis, various treatment outcomes exist.

Individualized treatment plans are recommended forthose diagnosed with AN/AD.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theeffectiveness of intervention methods on thosediagnosed with AN/AD. The secondary objective isto propose evidence-based recommendations oneffective intervention strategies for those withAN/AD based on current literature available.

Methods


PubMed. and PsyInfo.


review paper focused on benefits of hearing aids andcochlear implants for those diagnosed with AN/AD.


following types of articles congruent with theaforementioned selection criteria: longitudinalstudies, clinical and case studies.

Results

Cochlear ImplantsA study done by Shallop, Peterson, Facer, Fabry

and Driscoll (2001) looked at children’s speechperception performance pre-operatively and post-operatively (cochlear implants) in many differentassessment techniques. Preoperatively the childrenwere unable to discriminate speech with or withouthearing aids. This represents a category 1 on theEarly Speech Perception test. It was seen that all of

33

EFFECTIVENESS OF INTERVENTION METHODS FOR THOSE DIAGNOSED WITH AUDITORY NEUROPATHY/AUDITORY DYS-SYNCHRONY

the children moved from the category 1 to category 4postoperatively on the Early Speech Perception test.Three of the children had demonstrated open setword recognition on the Glendonald auditoryscreening procedure test. Four of the children hadgood EABR results. Therefore there was animprovement shown in speech outcomespostoperatively. The outcome therefore was shownby improvement in the five cases with respect toSAT, SRT, ESP and GASP speech tests used withinthe study.

Buss, Labadie, Brown, Gross, Grose andPillsbury (2002) identified four individuals diagnosedwith AN/AD between the ages of 2 and 3 years ofage. Pre and post-operative speech scores wereevaluated in order to measure the effectiveness ofcochlear implants and speech perception.Preoperative assessments were conducted andanatomical and physiological differences were notedbetween subjects. Communication modespreoperatively differed between subjects. The Paden-Brown test was administered to measure speechoutcomes post-operatively. Theses scores were thencompared to a group of pediatric subjects who wereimplanted with a cochlear implant at 4 to 6 years ofage without AN. Results show that three out of thefour subjects fell within or slightly above theconfidence interval one standard deviation around thecontrol group mean. One subject fell more than onestandard deviation below the mean, which waspossibly due to the use of manual communication athome post-operatively (Buss et. al, 2002).

Hearing aidsRance, Cone-Wesson, Wunderlich and Dowell

(2002) performed a study to investigate the unaidedand aided speech perception abilities of children withAN/AD and to compare their performance to childrenwith sensorineural hearing loss. Two groups ofchildren were tested, one group of subjects withAN/AD and one group of children with sensorineuralhearing loss. Unaided and aided pure-tone tests aswell as unaided and aided speech perception scoreswere measured. The history of amplification use,early intervention and communication strategies weredocumented.

With regards to speech perception, there was anobvious improvement with aided speech perceptionfor those with sensorineural hearing loss. Withregards to those with AN/AD, 7 of the 15 childrenshowed no significant improvement in speechperception with the use of hearing aids. There was alot of variability of aided speech scores amongstsubjects with behavioral thresholds in the mild-moderate hearing loss range.

Conclusions

Auditory Neuropathy/ Auditory dys-synchronypresents many intervention challenges that are verydistinct from those with sensorineural, conductive ora missed hearing loss (Doyle, Sininger & Starr,1998). Amplification via hearing aids or cochlearimplants provides assistance for most individualswith various hearing losses. AN/AD on the otherhand, is a very complex disorder that is currentlybeing greatly researched especially in the area ofmanagement and intervention strategies. “AN/AD isa disorder that affects neural processing of auditorystimuli that will reduce a child’s ability to understandspeech and may affect the ability to detect sound tovarious degrees” (Gravel, Hood, Lightfoot, Mason,Sirimanna, Stevens & Wood, 2004). Thereforeproviding amplification simply through hearing aidsand cochlear implants is not successful for allindividuals diagnosed with AN/AD.

Recommendations

Cochlear ImplantsResearch evidence supports the fact that cochlear

implants are beneficial for many individualsdiagnosed with AN/AD (Shallop et. al, 2001; Buss et.al, 2002). Many individuals with AN/AD whoreceive implants have similar outcome scores to otherpediatric implant patients without AN/AD.Physiologic data suggest that the implant is able toovercome the de-synchronization hypothesized tounderlie auditory neuropathy (Buss et. al, 2002).

Finally, all of the research evidence cited seemsto agree that the benefits of cochlear implants forthose with AN/AD is seen in most individuals. Dueto individual differences, audiologists must be awareof the complexity of the disorder and the differencesin success of treatment. Children with severe toprofound sensorineural hearing loss are routinelyimplanted and the outcomes in these cases have beenconsistent with the outcomes of patients withsensorineural hearing loss (Trautwein et. al, 2000;Shallop et. al, 2001). Therefore cochlear implantsbeing a permanent intervention method for those withAN/AD with severe-profound hearing loss, arerecommended due to successful outcomes outlinedwithin literature. Should we implant AN/ADchildren with mild to moderate hearing losses? Thisis an unanswered question within literature.

Hearing AidsIt is clearly seen that hearing aids do provide

benefit for some pediatric patients diagnosed withAN/AD (Rance et. al, 2002). Keeping in mind thatspeech perception ability cannot be reliably estimated

34

EFFECTIVENESS OF INTERVENTION METHODS FOR THOSE DIAGNOSED WITH AUDITORY NEUROPATHY/AUDITORY DYS-SYNCHRONY

from the behavioral audiogram in children withAN/AD, hearing aid prescriptions may be of concernwhen providing AN/AD children with appropriategain (Rance et. al, 2002). Therefore it is usuallyrecommended that a trial of hearing aids should beadvised when counseling parents of these children,even though only some AN/AD children benefit fromhearing aids. At this point we do not have a concreteunderstanding on which individuals will benefit fromhearing aids and which individuals will not benefitfrom hearing aids. Because of this unknown finding,a hearing aid trial is usually advised in all individualsdiagnosed with AN/AD. Hood (1998) has suggestedthat more conservative strategies such as monauralfittings, and/or low gain devices should be prescribedfor an individual with AN/AD. This strategy isadvised due to the fact that speech perception abilitycannot be reliably estimated from the behavioralaudiogram in children with AN/AD.

Therefore hearing aids as a non-permanentalterative option is advised for most or even allindividuals with AN/AD. Literature has shown thatsome individuals with AN/AD do gain benefit inspeech discrimination and audibility of sounds fromhearing aids.

In conclusion, it is strongly recommended thathearing aids be prescribed for most or all thosediagnosed with AN/AD. Whether the individualbenefits from hearing aids is individual specific.Amount of amplification and degree of loss may havean affect of hearing aids. Based on clinical studiesand case studies, conservative hearing prescriptionsshould be given when programming hearing aid(s)(Hood, 1998). If hearing aids are not providingbenefit, research evidence has recommended thatcochlear implants are an alternative method ofamplification for some individuals with AN/AD.

References

Berlin, C, Hood, L., Rose, K. (2001). Renamingauditory neuropathy as auditory dys-synchrony.Audiology Today 13: 15-17.

Buss, E., Labadie, R.F., Brown, C.J., Gross, A.J.,Grose, J.H., Pillsbury, H.C. (2002). Outcome ofcochlear implantation in pediatric auditoryneuropathy. Otology & Neurotology 23 (3): 328-332.

Doyle, K.J., Sininger, Y., Starr, A. (1998) Auditoryneuropathy in childhood. Laryngoscope 108 (9):1374-1377.

Fabry, L.B. Identification and management ofauditory neuropathy case study. www.phonak.ca

Gravel, J., Hood, L., Lightfoot, G., Mason, S.,Sirimanna, T., Stevens, J. & Wood, S. (2004)Newborn hearing screening; assessment andmanagement of auditory neuropathy/ auditorydys-synchrony- a recommended protocol.

Hood, L.J. (1998) Auditory neuropathy: what is itand what can we do about it? The HearingJournal, 51: 10-18.

Hood, L.J (1999) A review of objective methods ofevaluating auditory neural pathways.Larynngoscope 109: 1745-8.

Rance, G., Cone-Wesson, B., Wunderlich, J., Dowell,R. (2002) Speech perception and cortical eventrelated potentials in children with auditoryneuropathy. Ear and Hearing 23 (3) 239-253.

Shallop, J.K., Peterson, A., Facer, G.W., Fabry, L.B.,Driscoll, C.L. (2001) Cochlear implants in fivecases of auditory neuropathy: postoperativefindings and progress. Laryngoscope 111: 555-562.

Sininger, Y.S., Hood, L.J., Starr, A., Berlin, C.I. &Picton, T.W. (1995) Hearing loss due to auditoryneuropathy. Audiology Today 7:10-13.

Sininger, Y.S., Starr, A. Auditory neuropathy.Singular, 2001.

Sininger, YS (2002). Identification of AuditoryNeuropathy in Infants and Children. Seminars inHearing 23, No3, 193-200

Trautwein, P.G., Shallop, J., Fabry, L & Friedman, R.(2001) Cochlear implantation of auditoryneuropathy. Auditory Neuropathy: A NewPerspective on Hearing Disorders. SingularPublishing.

35

Copyright © 2005, D’Souza, F.A.

Impact of writing therapy on functional communicationin persons with aphasia

D’Souza, F.A.M.Cl.Sc. (SLP) Candidate


This critical review examines the effectiveness of writing therapy in improving functionalcommunication in people with aphasia. Study designs include: single case study, a within-subject control design and single-subject multiple- baseline case series design. Overall,research supports the use of writing therapy to improve functional communication in personswith aphasia; however due to the presence of serious design, methodological andmeasurement flaws, limitations to this conclusion exist.

Introduction

People with acquired aphasia present with arange of communicative abilities. Some individualsexperience difficulties with spoken and writtenlanguage because common language processes areimpaired (Robson et al., 2001). Understanding thelanguage deficit is a prerequisite for therapy and aidsin the choice of alternative modes of communication.It is often assumed that writing skills will be asimpaired as speech, since it requires access tophonology; however a review of language processingmodels has shown that writing may be achieved bydirect access to orthography without phonologicalmediation (Jackson-Waite et al., 2003). Research hasrevealed the importance of writing as an alternativeroute to communication in people with non-fluentaphasia (Armstrong et al., 2000, Beeson et al., 2002,Jackson-Waite et al., 2003 & Robson et al., 2001).

A range of treatment approaches are available forthe remediation of acquired writing impairments inaphasia. These treatments range from cognitiveneuropsychological approaches to less traditionalcomputer-based treatments. Four types of writingtherapy are addressed herein. These include the useof prosthesis and computerized trials, Anagram andCopy Treatment (ACT) paired with Copy and RecallTreatment (CART), use of a Lightwriter, andWritten Naming and Message Therapy to improvewritten expression. Research has not yet identified auniversally superior type of writing therapy thatimproves functional communication in persons withnon-fluent aphasia.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theeffectiveness of writing therapy in improvingfunctional communication in individuals withaphasia. The secondary objective is to propose

evidence-based practice recommendations about theuse of writing therapy in this population.

Methods

Search StrategyComputerized databases including PubMed,

Proquest and Psychinfo, were searched using thefollowing search strategy:

(Aphasia) OR (dysphasia) AND (Writing)AND (Therapy) OR (Writing) AND(Functional) AND (Communication)



review paper were required to investigate the impactof any type of writing therapy on functionalcommunication in individuals with aphasia.

Data CollectionAs per the selection criteria mentioned above,

results of the literature search yielded several studieson this topic, however the following types of articleswere selected: single case study (1), a within-subjectcontrol design (2) and single-subject multiple-baseline case series design (1).

Results

Impact of Prosthesis and Computerized writingtherapy on functional communication

Prosthesis trialsThe subject’s dominant but hemiplegic arm and

hand was aided with a mousepen and splintprosthesis, which was used to obtain writing outcomemeasures. Following prosthesis trials, results fromsubtest of the Test of Word Knowledge (TOWK)revealed that the subject’s word definitions consisted

36

IMPACT OF WRITING THERAPY ON FUNCTIONAL COMMUNICATION IN PERSONS WITH APHASIA

of longer, ungrammatical sentences with somesemantic errors (e.g. ‘write’ for ‘send’). Spellingerrors accounted for 18.75% of total words comparedto 35% of total words pre-prosthesis trials. Thesubject’s Western Aphasia Battery (WAB) picturedescription was twice as long as compared to pre-prosthesis, containing 40 words and three sentences(9, 15 and 15 words per sentence) with no spellingerrors. Spelling of regular words in the writingsubtest of the Psycholinguistic Assessment ofLanguage Processing (PALPA) was slightly better(18/20) than at baseline but the subject’s score didnot improve on exception words. Many of the errorsconsisted of letter omissions with only one letteraddition. Vowel errors were also evident (Armstronget al., 2000).

Computerized trialsA word-processing programme that provided

auditory feedback and word and grammaticalprediction was used to aid written languageexpression. Results post computerized trials revealedthat TOWK word definitions were more completegrammatically and longer than at base-lineassessment. Some spelling and grammatical errorswere still evident (8% of total words – 10% less thanwhen he was aided with the prosthesis). The subject’sWAB picture description was three sentences long(39 words -5, 14 and 20 words per sentence) andcontained two errors (5% of total words). His spellingperformance on the writing subtest of the PALPAshows a slight improvement for regular words and analmost 100% improvement in his score of exceptionwords (Armstrong et al., 2000).

At follow-up, when evaluating impact ofprosthesis versus computerized trials, it was foundthat the subject chose to use the computer to writeletters with the aid of the word-processing program(Armstrong et al., 2000).

Impact of ACT and CART writing treatment onfunctional communication

Written spellingFollowing ACT and CART writing treatment,

the subject was re-assessed using the PALPA subtestswhich included words that had not been trained. Allfour subjects showed little or no improvement inwritten spelling for untrained words. However,during treatment, one subject showed a notableincrease in his attempts to spell untrained words inthe context of group therapy. He showed increasingability to write the initial portion of words and tospell some words that had not been targeted fortreatment (Beeson et al., 2002).

Functional use of writing:All four subjects showed functional changes in

their use of writing for communication. Subject 1began to copy words from his communication bookand other sources in order to communicate specificinformation. He learned to write the names of hisphysicians and appropriately communicate anupcoming appointment to his clinician by writing thephysician’s name. He also showed increased use ofhis communication book to point to written words toclarify on-line communication with the clinician. Atfollow-up, clinical records showed the acquisition ofan additional 20 words (including nouns and verbs)over the course of 12 weeks (Beeson et al., 2002).Subject 2 increased his attempts to use writing tocommunicate in group and individual therapysessions, with improved effectiveness in thoseattempts. The subject demonstrated increased wordform knowledge for untrained words. At a thirteenmonth follow-up, he continued to target new words tolearn and use in written communication (Beeson etal., 2002). Subject 3 showed improvement in spellingthat was adequate to get the subject started whileusing email. The subject copied the spellings foruntrained words from written sources or obtainedhelp from family members. He wrote the messagesby hand and then typed them into the computer. Hise-mails were agrammatic but meaningful, and had thebenefit of evoking a response from the recipient(Beeson et al., 2002). Subject 4 increased his use ofwriting during conversation (Beeson et al., 2002).

Impact of the use of a Lightwriter on functionalcommunication

Access to orthographic informationThe increase in treated words correct after

therapy (19) compared to pre-therapy (1) wassignificant (p<.001). No change was seen in thecontrol words. Handwritten words written correctlyincreased from 1 pre-therapy to 6 post-therapy with16 items written partially correct. Eight weeks later,performance had declined to 11 treated words correctcompared to 19 post-therapy. Nonetheless, thisremained significantly better than before therapy(p<.01). The increase in treated words partiallycorrect post-therapy (14) compared to pre-therapy (7)indicates retained access to the orthography of treatedwords (Jackson-Waite et al., 2003).

Generalization of written vocabularyAfter therapy, 20 words from the treated list

were correct as compared to only three from beforetherapy. The difference was significant (p<.001).Partially correct and first letter responses alsoincreased. At follow-up 8 weeks later, the subject

37


produced 14 items correct which is significantly morethan before therapy (p<.01) (Jackson-Waite et al.,2003).

Functional communication with a LightwriterIn a questionnaire designed to resemble a

conversation (e.g. Where are the nearest shops?), thenumber of questions answered on the Lightwriterincreased significantly from 2 before therapy to 12afterwards (p<.05). Of the 12 correct items, 7 werefrom a list of untreated words. Nonetheless, thesubject needed prompting to use the Lightwriter andrarely made functional use of it outside the clinicalsetting (Jackson-Waite et al., 2003).

Impact of Written Naming and Message Therapy onfunctional communication

Written Naming and Message therapyAll six subjects made more correct responses

after therapy. Four showed significant gains (p<0.05)on the treated words after therapy and two remainedsignificantly better at follow-up (p<.05). Many errorswere approximations to the target word. All subjectsmade a significant improvement on the number ofcorrect letters in responses (Robson et al., 2001).Only one out of the six subjects failed to showsignificant gains at the follow-up assessment a monthlater. No subject made gains on the untreatedvocabulary (Robson et al., 2001). After Messagetherapy all subjects increased their correct responsesto treated items, but only the gains of one subjectwere found to be significant (Robson et al., 2001).

Functional use of writing:Following therapy, all subjects used writing

spontaneously during conversations aboutcontemporary events, holidays and family intherapist-led sessions. Three subjects producedrecognizable approximations to treated words, suchas the names of a son and grandchild when describingfamily to a volunteer. On other occasions, subjectsused untreated words. At three months follow-up,caregivers reported that subjects were using writingwith other conversational partners (Robson et al.,2001.

Discussion

Overall results from these studies support the useof writing therapy to improve functionalcommunication in persons with non-fluent aphasia(Armstrong et al., 2000, Beeson et al., 2002 &Robson et al., 2003). In the interpretation of theirfindings, some authors provided cautionary notes andaddressed issues of clinical versus statistical

significance. Essentially this promotes the use ofwriting therapy clinically. However it is important tonote that findings from a critical appraisal of thesestudies display serious design, methodological andmeasurement limitations that are significant enoughto potentially have a major impact on these findings.These limitations include: the selection of a researchdesign, sample size, outcome measures andmeasurement tools.

Research Design: The selection of single casestudies and single subject multiple baseline researchdesigns provide the lowest level of research evidence.These are subject to numerous threats to validity thatthe researchers did not control for (Portney &Watkins, 2000). This resulted in the presence ofseveral biases and confounding variables such as theinfluence of multi-stage treatments and otherconcurrent treatments, testing effects, subjectmaturation, experimenter bias and the Hawthorneeffect. The uncontrolled threats to design validitypresent in these studies may show statisticallysignificant positive outcome measures for writingpost-therapy, which may not be a true effect of theintervention (Herzberg, 1983). Only two of the fourstudies clearly stated who administered the therapy(Beeson et al., 2002 & Robson et al., 2001).Therefore, findings from all four studies must beinterpreted with caution because of increased risk ofsubjectivity embedded in its’ analysis.

Subject size: Due to the nature of the researchdesigns employed, the very small sample size andlack of control group can only provide evidence forthe efficacy of a specific writing treatment with aspecific person with aphasia. As a result, thesestudies do not possess high external validity and theoutcomes cannot be generalized to other individualsor situations (Portney & Watkins, 2000).

Outcome measures: Researchers did not includeoutcome measures of variables that fully encompassfunctional communication. Measures such as thefrequency and/or type of grammatical and spellingerrors made, the subjects’ success rate incommunicating a message through the use of writing,and the use of written communication to shareabstract ideas, feelings and emotions were notcollected. It is possible that these additional outcomemeasures were not considered due to the absence ofan operational definition of functionalcommunication in the literature.

Measurement tools: There were limitations in theselection of measurement tools to measure writtenoutput for functional communication. Someresearchers used findings from informal, unstructuredclinical interactions to comment on generalizationand use of writing for functional purposes withminimal empirical data to support their claim

38


(Armstrong et al., 2000 & Robson et al., 2001). Sincethese tests are not standardized their psychometricproperties are unknown, moreover the authors did notaddress this as a concern. Other studies utilizedsubtests from standardized tools to measure writingoutcomes (Armstrong et al., 2000 & Beeson et al.,2002). However, the reliability and validity of thesubtests administered in isolation were not stated,therefore the outcome measures obtained cannot beaccepted with full confidence. Overall, thesemeasurement tools alone fail to adequately evaluatecommunication for functional purposes. Researchersdid not include rating scales or other tools that wouldenable the subject and his/her communication partnerto evaluate their success in conveying a messagethrough the use of writing. Researchers may not havereported such positive results had they controlled forthe design and methodological limitations mentionedabove.

Given the research design, sample size and typeof outcome data collected, three out of the fourstudies utilized an appropriate method for analysis ofthe results (Armstrong et al 2000., Beeson et al., 2002& Jackson-Waite et al., 2003). Robson et al., (2001)inappropriately employed parametric statistics oncategorical data (Portney & Watkins, 2000).Researchers from only two of the four studiesexplicitly stated cautionary notes about their resultfindings (Beeson et al., 2002 & Robson et al., 2001).The overall findings for the functional use of writingwas predominately restricted to treated words onlyand required a familiar communication partner and/orcontext for its’ interpretation. This presents withobvious limitations for use in everydaycommunication. In order to provide evidence basedsupport for the use of writing therapy with thispopulation, future research should adequately addressthese limitations.

Conclusions

Research has revealed the importance of writingas an alternative route to communication in peoplewith non-fluent aphasia (Armstrong et al., 2000,Beeson et al., 2002, Jackson-Waite et al., 2003 &Robson et al., 2001). Three of the four studiesexamined report results that suggest the use ofwriting for functional communication purposes afterwriting therapy was administered (Armstrong et al.,2000, Beeson et al., 2002 & Robson et al., 2001).However, all four studies had serious design,methodological and measurement limitations thatwere significant enough to potentially have a majorimpact on the results reported.

To support the clinical use of writing therapy toimprove functional communication in this

population, rigorous research that effectivelyaddresses these limitations is needed. Future researchshould operationally define ‘functionalcommunication’ so that suitable outcomes aremeasured. Furthermore, research should implementmeasurement tools that appropriately measure thisoutcome. A larger N size would be ideal since itwould take in to consideration the level ofconfidence, margin of error tolerated, and variabilityin the population studied (Herzberg, 1983). Overall,this cohort would be more representative of the targetpopulation and would result in greater externalvalidity and thereby increased general utility (Portney& Watkins, 2000).

In the meantime, it would be recommended touse writing therapy with this population as it providesthese individuals with a valuable means tocommunicate. However, in order to provide evidencebased support for the clinical use of writing therapyto improve functional communication in people withaphasia, future research should adequately addressthe research limitations mentioned herein whilereporting positive writing outcomes for functionalcommunication.

References

Armstrong L, MacDonald A. (2000) Aiding chronicwritten language expression difficulties: A casestudy. Aphasiology, 14(1), 93-108.

Beeson P, Hirsch F, et al. (2002). Successful single-word writing treatment: Experimental Analysesof four cases. Aphasiology, 16(4/5/6), 473-491.

Herzberg P. (1983). Principles of Statistics. p.286-299. Krieger Publishing Company, Florida.

Jackson-Waite K, Robson J, et al. (2003). Writtencommunication using a Lightwriter inUndifferentiated jargon aphasia: A single casestudy, Aphasiology, 17(8), 767-780.

Portney, L.G., & Watkins, M.P. (2000). Foundationsof Clinical Research Applications to Practice(2nd ed). Upper Saddle River, New Jersey:Prentice Hall Health.

Robson J, Marshall J, et al. (2001). Enhancingcommunication in jargon aphasia: a small groupstudy of writing therapy. International Journalof Language and Communication Disorders,36(4), 471-488.

39

Copyright © 2005, Dempsey, L., Lee, C., & Skarakis-Doyle, E.

Understanding the constructs underlying narrative comprehension in youngchildren: The role of vocabulary

Dempsey, L., M.Sc.1,2, Lee, C., Ph.D.3, Skarakis-Doyle, E., Ph.D.2

1Doctoral Program in Rehabilitation Science, The University of Western Ontario, London, Ontario2School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario3School of Occupational Therapy, The University of Western Ontario, London, Ontario

This study examined the role of vocabulary comprehension in young children’s comprehension ofa script-based narrative. Twenty-nine normally developing children between 30 and 70 monthscompleted two vocabulary tests, the PPVT-III, and a story-specific test, a memory measure, andtwo measures of narrative comprehension. Analyses revealed that story comprehension was morestrongly correlated with general vocabulary comprehension than with specific story vocabularyknowledge, a finding consistent with the view that vocabulary comprehension is an index offundamental language ability. However, when memory was controlled for the relationshipbetween the PPVT-III and story comprehension was nonsignificant, suggesting that memory maybe the key construct underlying both abilities in young children.

40

Copyright © 2005, Doyle, P.C., Beaudin, P.G., Eadie, T.L., Anderson, J., & White, H.D.

Written measures of voice handicap:A concurrent validity assessment of the VHI & VRQOL

Doyle, P.C., Ph.D.1,2, Beaudin, P.G., M.Sc.1,2, Eadie, T.L., Ph.D.1,2,3,Anderson, J., M.D.4, White, H.D., M.Sc.1,5

1Voice Production and Perception Laboratory, The University of Western Ontario, London, Ontario2Doctoral Program in Rehabilitation Science, The University of Western Ontario, London, Ontario3Department of Speech and Hearing Sciences, University of Washington, Seattle, Washington4Voice Disorders Clinic, Department of Otolaryngology, St. Michael’s Hospital, Toronto, Ontario5School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario

The relationship between two written measures of voice handicap and voice-related quality of lifewas assessed. Sixty-five individuals seen for initial voice evaluation completed the 30-item VoiceHandicap Index and the 10-item Voice-Related Quality of Life. Correlational analysis between thetwo instruments indicated a strong relationship. Results will be discussed relative to the clinicalapplication of these instruments.

41

Copyright © 2005, Doyle, P.C., Beaudin, P.G., DeLuca, M., Black, M., Eadie, T.L., Anderson, J., Lim, M., Luong, V.

Quantifying acoustic signal variabilityin adductor spasmodic dysphonia (ADSD)

Doyle, P.C., Ph.D.1,3, Beaudin, P.G., M.Sc.1,2, DeLuca, M., M.Cl.Sc.4, Black, M., M.D.5,Eadie, T.L., Ph.D.1,2, Anderson, J., M.D.4, Lim, M., B.H.Sc.1,7, Luong, V., B.Sc. 1,8

1Voice Production and Perception Laboratory, The University of Western Ontario, London, Ontario2Doctoral Program in Rehabilitation Science, The University of Western Ontario, London, Ontario3School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario4Voice Disorders Clinic, Department of Otolaryngology, St. Michael’s Hospital, Toronto, Ontario5Otolaryngology Head and Neck Surgery, McGill University, Montreal, Quebec6Department of Speech and Hearing Sciences, University of Washington, Seattle, Washington7Schulich School of Medicine, The University of Western Ontario, London, Ontario8Department of Biophysics, The University of Western Ontario, London, Ontario

This presentation outlines inherent limitations related to the interpretation of acoustic measuresgathered from abnormal vocal signals generated by individuals diagnosed with focal laryngealdystonia. Contiguous measures from multiple tokens of sustained vowels (/a/, /i/, /u/) weregathered from 6 participants diagnosed with adductor spasmodic dysphonia (ADSD). Datapertaining to standard deviation of fundamental frequency, frequency and amplitude perturbation,and noise-to-harmonic ratio are presented.

42

Copyright © 2005, Doyle, P.C., Eadie, T.L., Beaudin, P.G., White, H.D., Cagnin, D., & Newell, C.

Voice-related quality of life in alaryngeal speakers

Doyle, P.C., Ph.D.1,2, Eadie, T.L., Ph.D.1,3,4, Beaudin, P.G., M.Sc.1,3,White, H.D., M.Sc.1,2, Cagnin, D.1,5, Newell, C.1,5

1Voice Production and Perception Laboratory, The University of Western Ontario, London, Ontario2School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario3Doctoral Program in Rehabilitation Sciences, The University of Western Ontario, London, Ontario4Department of Speech and Hearing Sciences, University of Washington, Seattle, Washington5Bachelor of Health Sciences Program, The University of Western Ontario, London, Ontario

This project assessed use of the Voice-Related Quality of Life (VRQOL) in a group of 50laryngectomized speakers. Participants completed this validated, 10-item questionnaire fromwhich social-emotional, physical functioning, and total scores were calculated. Findings revealeddifferential scores in each domain by alaryngeal speech type and gender. The implications relativeto rehabilitation will be outlined.

43

Copyright © 2005, Freiburger, M.K.

Music therapy and its effect on verbal expression in dementia

Freiburger, M. K.M.Cl.Sc. (SLP) Candidate


This critical appraisal discusses the effect of music therapy (MT) on the verbal expression ofindividuals who have dementia of the Alzheimer’s type. The studies include: one group pretest –posttest, and quasi-experimental designs. At this time, strong research evidence to support the useof MT as a means of improving verbal expression in the target population is limited.

Introduction

The number and proportion of individuals overthe age of 65 has been climbing steadily in NorthAmerica due to life expectancy changes anddemographic characteristics (Koger et al., 1999). Asa consequence there are increasing demands to gain agreater understanding of the specific social,psychological and physical needs of this agingpopulation (Brotons et al., 1997). Dementia ischaracterized in the American PsychiatricAssociation’s Diagnostics and Statistical Manual - IV(DSM-IV) (1994) as a syndrome comprised ofimpairment in cognitive functioning, includingdeficits in language (aphasia), short- and long-termmemory, judgment, abstract thinking, and changes inpersonality. These impairments may interfere withan individual’s daily activities (i.e. work, socialactivities, and relationships). Dementia of theAlzheimer’s type (DAT) is the most commonlydiagnosed, followed by multi-infarct dementia, andmixed dementia (i.e. combination of DAT and multi-infarct types) (Brotons & Koger, 2000; Grasel et al.,2003). The prevalence of dementia increases withage, and subsequently the elderly make up the largestpopulation affected by it. By the year 2040, it isestimated that 12 to 14 million individuals will beaffected by dementia (Brotons et al., 1997). There isno known preventative measure or cure for dementia,and drug therapies have limited effectiveness (Graselet al., 2003). For these reasons, the examination ofthe role of non-drug therapies, including musictherapy, is critical if health professionals wish toaddress the needs and quality of life of this growingpopulation.

Music therapy for individuals with dementiaconsists of a range of activities from passivelylistening to music to musical improvisation exercises(Grasel et al., 2003). Researchers have found thatdespite their limitations, individuals who havedementia continue to respond to and sing old songs,and dance to old melodies (Brotons et al., 1997). It ispostulated then, that music therapy helps individualswith dementia compensate for their deficits by

providing them with a means of expressingthemselves (Grasel et al, 2003).

Objectives

The objective of this review is to criticallyexamine a sample of literature focusing on MT as ameans of facilitating verbal expression in dementia.Recommendations regarding the use of MT withinspeech-language pathology, and avenues for futureresearch will also be discussed.

Methods

Search StrategyComputerized databases were searched,

including EBM Reviews, PsycInfo, and ProQuestPsychology Journals. Keywords used include:

(dementia) OR (Alzheimer’s) AND (musictherapy) OR (music*) AND (verbalexpression) OR (language) OR(communication) OR (social skills).

The search was limited to articles written inEnglish.

Selection CriteriaThe studies included in this critical appraisal

were required to examine the effect of any type ofmusic therapy on the expressive communicationamong individuals with dementia of the Alzheimer’stype. No restrictions regarding outcome measureswere applied.

Data CollectionThe results of the literature search yielded the

following study types: one group pre-test post-testdesigns (2), and quasi-experimental designs (2).

Results

In their study, Olderog Millard and Smith (1989)used a single group, reversal ABABA design, wherecondition A was a discussion session, and condition Ba singing session. One of their hypotheses was that

44

MUSIC THERAPY AND ITS EFFECT ON VERBAL EXPRESSION IN DEMENTIA

social behaviours, including verbal participation,would be significantly higher during and/orimmediately after singing, rather than during or afterdiscussion sessions. Outcomes were measured usinga frequency of social behaviour checklist created bythe authors. The researchers used a 2-way (A x B xSubjects) within subjects ANOVA to analyze thedata. This analysis revealed that the amount ofvocal/verbal participation was significantly higher (p< .05) during therapeutic music sessions than duringdiscussion sessions. No significant increases in verbalbehaviours following music therapy versusdiscussion were reported. Reportedly, thesignificantly increased verbal participation duringmusic therapy, as compared to the discussioncondition, can be attributed to the fact that, althoughseveral subjects rarely spoke, they did sing whengiven the opportunity. The music therapy thereforeencouraged the subjects to participate more in thesession.

Brotons and Koger (2000) used a within-subjectscounterbalanced design to explore the effects of MTversus discussion on language ability outcomes in 26people with dementia. They hypothesized that MTwould significantly affect language functioning asmeasured by the Western Aphasia Battery (WAB).To analyze the data, the researchers used a 2-wayrepeated measures ANOVA. They reportedsignificant main effects for music versus discussion(p=.01), with significant improvement in the speechcontent and fluency dimensions of the spontaneousspeech subscale following MT (p=.004).Performance in the fluency dimension wassignificantly better than the performance in thecontent dimension across both conditions. Thisfinding supports previous reports of fluency beingpreserved longer than content in dementia. Nosignificant interaction was calculated between musicand conversation conditions. In addition, nosignificant differences in the Aphasia Quotient or inauditory-verbal comprehension were found. Aneffect size for overall Aphasia Quotient differencesbetween condition was calculated as r = .257. Thiseffect was not significant; however the researchershypothesized that this effect may be clinicallysignificant.

Pollack and Namazi (1992) employed a one-group pretest-posttest design to evaluate theeffectiveness of MT on social behaviour outcomes,including verbal interaction. A behaviour frequencychecklist was used to measure the outcomes beforeand after treatment. A Chi-square test revealed asignificant increase of 24% in social behaviour(p<.001), and a significant decrease in non-socialbehaviour of 14% (p<.001). When raw scores werecompared, increases were observed in all types of

social behaviour, including verbal behaviour. It wasnot reported whether this increase was statisticallysignificant. The greatest gains were observed fornonverbal social behaviours. Narrative observationsthat the observer made during MT sessions, revealedthat subjects were generally cooperative anddisplayed increased verbalization and positive verbalfeedback. These observations were not quantified bythe behaviour checklist.

Sambandham and Schirm (1995) hypothesizedthat planned music sessions would exert a positivechange in subjects’ communication and socializationskills. A one-group pre-test-posttest design was usedto compare differences in the frequency of socialbehaviours, including verbal expression. Thesebehaviours were measured using the Music TherapyAssessment Tool before, during, and after musicsessions. Statistical analysis was conducted using ananalysis of variance (ANOVA). The ANOVArevealed significant differences among subjects’verbal behaviours. Subjects talked less during themusic sessions, compared to before and after thesessions. Significantly more resident verbalizationsand non-verbal expressions were recorded during the20-minute observation time-frame, following themusic sessions, as compared to before and during thesessions.

Discussion

Appraisal of the ResultsAt first glance the research evidence appears to

indicate that MT does have a positive effect onbehaviours related to verbal expression in individualswith dementia. However, numerous issues in regardsto subject selection, methodology, and statisticalanalyses exist in the literature. These issuesnegatively impact the strength of the evidence.

Subject SelectionThe most notable issue with the kind of sampling

that the researchers have used in all the studiesexamined, is that there was a lack of randomselection. Without random selection from thedementia population, one must be sceptical as towhether the samples taken were representative of thegreater population of individuals who have dementia.This ultimately affects the generalizability of theirresults.

MethodologyIt is important to interpret the results of each

study with caution, as there are methodological flawsassociated with each study. There are sources of biasthat may have influenced the evidence described. Forexample, in 3 of the 4 studies the investigators did

45


not use blind observers (Olderog Millard & Smith,1989; Pollack & Namazi, 1992; Sambandham &Schirm, 1995). The unconscious expectations of theobservers may have accounted for the differencesdisplayed in the results. Other explanatory factorsintroduced by weak research designs may haveaccounted for some of the results. For instance, inthe studies that utilized one group pre-test post-testdesigns (Pollack & Namazi, 1992; Sambandham &Schirm, 1995) threats to internal validity, or socialinteraction with the therapist or others, may explainor have influenced the results. Furthermore, it isquestionable as to whether the outcome measuresused, fully capture the construct of verbal expression,and whether these outcomes are clinically importantin terms of the functional communication and qualityof life of individuals who have dementia. In addition,the measurement tools used to quantify the outcomemeasures may not have been appropriate, reliable, orvalid. For instance, Brotons and Koger (2000) usedthe WAB to measure language ability in theirsubjects following MT. However, the WAB wasstandardized on individuals with aphasia, excludingthose with concomitant dementia. Whether it wasappropriate to use the WAB with this population canbe called into question.

Statistical AnalysesSome of the investigators may have chosen

inappropriate statistical procedures to test thesignificance of their data. For example,Sambandham and Schirm (1995) conducted anANOVA on data that was ordinal in nature. A non-parametric test should have been used, such as theWilcoxon T Test for dependent samples (Morgan &Griego, 1998). Errors such as this weaken thestatistical validity of the reported evidence.

Recommendations

It is difficult to have confidence in the evidencedescribed, due to issues in subject selection,methodology, and statistical analyses. It is alsochallenging to make comparisons across the studiesbecause of differences in MT approach, researchdesign, and selected outcomes. Due to issues foundwithin and across the studies, it is unwise at this time,to attempt to make overall generalizations regardingmusic therapy’s effects on verbal expression inpeople with dementia. Whether MT is an effectivemeans of improving verbal expressive outcomes inthis population needs to be further specified. Untilstronger evidence is made available to support its use,it is not recommended that MT be integrated withinspeech-language therapy for adults who havedementia, for the sole purpose of improving

expressive language. It is recommended that moreresearch, including replication of previous studies, beconducted to clarify this research problem.Furthermore, researchers working in this area arestrongly encouraged to:

a) Delineate the optimal type/approach,frequency, and amount of MT required toinduce positive change in individuals whohave dementia (i.e. operationally definewhat conventional MT should be for adultswith dementia).

b) Use outcome measures that fully encompassthe construct of verbal expression, and thatare believed to be clinically significant.

c) Employ measurement tools that are reliable,valid, and standardized on the population ofinterest.

d) Apply data collection practices thatminimize potential sources of bias (e.g.blind observers).

e) Utilize strong research designs to minimizepossible sources of bias and/or confoundingfactors.

f) Specify further what symptoms associatedwith dementia are most amenable to change.For instance, MT may have a moresignificant impact on aggression, caregiverburden, or social skills, than on verbalexpression. Olderog Millard and Smith(1989) and Pollack and Namazi’s (1992)results suggest that MT may facilitate socialparticipation.

Limitations

It should be noted that there are limitations tothis critical review. First, the review focused on onlya sample of the research available. Only studieswritten in English and available in the publishedliterature were included in the review. This reviewwas by no means exhaustive, which introduces thepossibility that some significant research may havebeen missed. Secondly, the information reported inthe literature and discussed above, can only beapplied to individuals in the middle/moderate tosevere stages of dementia of the Alzheimer’s type,who are institutionalized, and not to those with milddementia, other diseases of the brain, or toindividuals with dementia who are living at home.

Conclusion

It can not be said that MT is not a usefultreatment, and should never be integrated intospeech-pathology practices. The investigators didfind significant results. However, it is difficult to

46


have confidence in the evidence because of issuesrelating to outcome measures, research design, datacollection methods, and statistical analyses. In time,it may be demonstrated that MT is an effective meansof facilitating verbal expression in dementia. MT,with further research, could be indicated as a way ofimproving other communication based outcomessuch as social participation and/or verbal fluency(Olderog Millard & Smith, 1989; Brotons & Koger,2000). Finally, MT may induce positive change inother populations that speech-language pathologistsoften encounter (e.g. children who have autism)(Bronte-Tinkew & Magill, 2004). MT’s utility as away of improving communication cannot yet be ruledout.

References

American Psychiatric Association. (1994).Diagnostic and Statistical Manual of MentalDisorders Fourth Edition. Washington, D. C.:American Psychiatric Association.

Bronte-Tinkew, B., Magill, R. (2004). An innovativedual-discipline approach to communicationtherapy: Music therapy and speech pathology.OSLA Perspectives, 1, 1, 12-17.

Brotons, M., & Koger, S. M. (2000). The Impact ofMusic Therapy on Language Functioning InDementia. Journal of Music Therapy, 3, 183-195.

Brotons, M., Koger, S. M., Pickett-Cooper, P. (1997).Music and Dementias: A Review of Literature. Journal of Music Therapy, 4, 204-245.

Grasel, E., Wiltfang, J., Kornhuber, J. (2003). Non-drug therapies for dementia: An overviewof thecurrent situation with regard to proof ofeffectiveness. Dementia and Geriatric CognitiveDisorders, 15, 3, 115-126.

Koger, S. M., Chapin, K., Brotons, M. (1999). IsMusic Therapy an Effective Intervention forDementia? A Meta-Analytic Review of theLiterature. Journal of Music Therapy, 1, 2-15.

Morgan, G. A., & Griego, O. V. (1998). Easy use andinterpretation of SPSS for Windows: Answeringresearch questions with statistics. Mahwah, NJ:Lawrence Erlbaum Associates.

Olderog Millard, K. A., Smith, J. M. (1989). TheInfluence of Group Singing Therapy on theBehavior of Alzheimer’s Disease Patients.Journal of Music Therapy, 26, 2, 58-70.

Pollack, N. J., Namazi, K. H. (1992). The Effect ofMusic Participation on the Social Behavior ofAlzheimer’s Disease Patients. Journal of MusicTherapy, 29, 1, 54-67.

Prickett, C. A., & Moore, R. S. (1991). The use ofmusic to aid memory of Alzheimer’s patients.Journal of Music Therapy, 28, 101-110.

Sambandham, M., Schirm, V. (1995). Music as aNursing Intervention for Residents withAlzheimer’s Disease in Long-Term Care. Geriatric Nursing, 16, 2, 79-83.

Shavelson, R. J. (1996). Statistical Reasoning for theBehavioural Sciences 3rd Ed. Needham Heights,Massachusetts: Allyn & Bacon. 473.

47

Copyright © 2005, Giberson, A.

Is there evidence to support treating language with intensive behavioralintervention programs such as ABA in children with autism?

Giberson, A.M.Cl.Sc. (SLP) Candidate


This critical review examines the effects of treating language using an intense behavioralintervention program for children with autism. Study designs include: between-subjects, one grouppre-test post-test, case study, within-subject longitudinal and comparison study. Overall, researchsupports that intense behavioral intervention is effective in increasing language and cognitivedevelopment in children with autism; however, future research needs to address whether acombination of intervention modalities is as effective as intense intervention alone.

Introduction

In the 1960’s Dr. O. Ivar Lovaas from UCLAdeveloped a type of intervention to treat children withautism derived from the principles of behaviorismdescribed by B.F Skinner. He coined the termApplied Behavioral Analysis (ABA) to describe thistype of treatment (Rosenwasser and Axelrod, 2001).This type of intervention incorporated terms andprinciples of behaviorism to treat communicative,cognitive and social impairments, aggressivebehaviors as well as any other impairments present inchildren diagnosed with a pervasive developmentaldisorder.

Applied Behavioral Analysis is an intensestructured teaching program that involves elicitingdesired responses from the person with autism. Thebasic concept of ABA is that responses are taughtusing repeated trials where the child is presented witha stimulus (like "pick up the toy"). Correct responsesand behaviors are rewarded with positivereinforcement such as praise, stickers or treats. Whenincorrect or undesirable responses occur, they areignored and appropriate responses are prompted andrewarded (Ogletree and Oren, 2001).

Currently, controversy exists surrounding thebehavioral approach to language treatment.Controversy surrounds the amount of time necessaryfor intervention, the age at which intervention is mosteffective, home-based vs. school-based and finally,whether these children benefit from a combination oftreatment modalities.

Objectives

The primary objective of this paper is tocritically evaluate existing literature to determinewhether there is evidence to support treating thelanguage of children with autism with intensivebehavioral intervention programs such as ABA aswell as look at the controversy surrounding this. The

secondary objectives are to propose evidence-basedpractice for future research looking at using anintense behavioral intervention method with childrenwith autism.

Methods

Search StrategyComputerized databases, including PubMed and

Proquest were searched using the following strategy:(behavioral intervention) OR (ABA) OR(applied behavioral analysis) AND(language) OR(communication) AND(autism) OR (pervasive developmentaldisorder).


Selection CriteriaTo be included in this critical review, studies

must have investigated the impact of any type ofintense behavioral intervention on language outcomesfor children autism. No limits were set on thedemographics of research or outcome measures.

Data Collection Results of the literature search yielded the

following types of articles: between- subject design(1), one group pre-test- post- test design (1), casestudy (1), within- subject longitudinal design (1) andcomparison study (1).

Results

Impact of Intensive Behavioral Intervention onLanguage Outcomes

Educational Placement and IQCompletion of an intense behavioral intervention

(40 hours a week for 2 years) looking at educationalplacement and IQ scores (which includes language

48

TREATING LANGUAGE WITH INTENSIVE BEHAVIORAL INTERVENTION PROGRAMS, IN CHILDREN WITH AUTISM?

scores) pre and post treatment resulted in significantimprovements (p<.001) for educational placementand (p<.01) for IQ in a sample of 19 children agedless than 46 months. (Lovaas, 1987).

Overall, 47% of children in the experimentalgroup passed through normal first grade with anaverage of 30 points gain in IQ. Lovaas also foundthat mental age was significantly (p < .03) related tooutcome in both groups. These results suggest that achild with a lower mental age (more severe autism)will most likely benefit from intense behavioralintervention.

Home-Based Intervention Rates of Skill AcquisitionWeiss (1999) studied a home-based behavioral

intervention approach (with parents trained toprovide 40 hours of instruction per week for 2 years)looking at the acquisition rate of non-verbalimitation, object manipulation, identical objectmatching, receptive commands and receptive labels.Among 20 children receiving early intense behavioralintervention, the acquisition rate of the abovevariables compared to the overall rate of skillacquisition was (p < .001). The acquisition rate ofthese variables was correlated with changes inadaptive functioning and in the severity of autism.This suggests that children who learned quicklyshowed the greatest changes in autism severity andadaptive behavior.

Overall, the study demonstrated that intensebehavioral intervention was beneficial for childrenwith autism, however more improvements may havebeen observed in those children exhibiting difficultyin skill acquisition had intervention incorporatedother behavioral approaches such as the PictureExchange Communication System (PECS).

High-risk children and language developmentA Case Study by Green et al. (2002) was done to

determine whether intense behavioral interventionwould improve the intellectual functioning of a childwith high-risk of developing autism. Over the courseof 4 years, the child made large gains in receptive andexpressive language as well as social and cognitiveskills. She progressed from exhibiting substantialdelays in multiple areas to functioning at or aboveage level in all areas. These results suggest thatintense behavioral intervention was successful inincreasing the child’s intellectual and cognitiveabilities to a level of function appropriate to herchronological age (Green, Brennan & Fein, 2002).

Intellectual Functioning and Home-BasedIntervention

Sheinkopf & Seigel, (1998) evaluated the impactof intense behavioral intervention on IQ scores on

children with autism when implemented by parents.Comparisons of IQ scores between 11 childrenbetween the ages of 23-47 months yielded results of(p < .01) post-treatment. This suggests that intensebehavioral intervention is effective in treatingchildren with autism, even when implemented byparents trained in behavioral intervention.

Behavioral vs. Eclectic Intervention with olderchildren

Eikeseth et al. (2002) compared results ofbehavioral intervention implemented at school vs.other traditional intervention methods such as ProjectTEACH and sensory-motor therapies for childrenwith autism aged 4-7 years. The results yieldedsignificant differences for IQ (p < .01), language (p<.05) and adaptive behavior (p<.05) for thebehavioral group. This suggests that those childrentreated with a behavioral approach did significantlybetter than those treated using other interventionmethods (Eikeseth, Smith, Jahr & Eldevick, 2002).

Critical Appraisal of Research

StrengthsEach article reported significance with very

small sample sizes (between 9-20 subjects) and hadappropriate statistical measurement and interpretationof results, which lends credibility to the results.

WeaknessesMost articles displayed weaknesses in the

generalizability of research participants, anddiscriminant validity measures as well as effect size,clinical significance and “goodness of fit” tests.However, research evidence is strong enough tosupport the use of intense behavioral intervention inspite of methodological and statistical flaws sinceeach study found approximately the same final result(that ABA was effective in treating language andother cognitive problems in children with autism) andthat there were no flaws in the appropriateness of thestatistical tests used.

Conclusions

The research on intense behavioral interventionhas been consistent in regards to the effectiveness intreating language delays as well as other intellectualand cognitive delays in children with autism.However, several things need to be considered beforeadministering this type of intervention. It is importantthat research looks at the general population in amore random, un-biased way in order to assesswhether children from other SES and ethnicbackgrounds will achieve the same results as those

49

TREATING LANGUAGE WITH INTENSIVE BEHAVIORAL INTERVENTION PROGRAMS, IN CHILDREN WITH AUTISM?

reported in the studies. It is also important thatresearcher’s compare their results of testing withother researchers in order to determine whether raterbias accounts for observed results. More importantly,ABA type intervention would perhaps be moreclinically significant if it were used in combinationwith other methods. All the studies administeredintense therapy requiring approximately 20-40 hoursper week. It is unrealistic in practice to devote thismuch time to therapy. Perhaps, a combination ofother traditional speech therapy methods as well asbehavior based interventions such as the PictureExchange Communication System (PECS) wouldhave more clinical applicability and thus, morerelevance.

Future studies should look at various treatmentmodalities, as mentioned above, and how thesecompare to those of equal or lesser intensity. Futurestudies should also look at whether results of therapyremain successful outside the therapy setting in orderto determine the success of the intervention.

References

Delprato, Dennis J (2001). Comparison of DiscreteTrial and Normalized Behavioral LanguageIntervention for Young Children with Autism;Journal of Autism and Developmental Disorders,31(3), 315-325.

Green, Gina; Brennan, Lynn C., Fein, Deborah(2002). Intensive Behavioral Treatment for aToddler at High Risk for Autism; BehaviorModification, 26(1), 69-102; Sage Publications.

Lovaas, Ivar O (1987). Behavioral Treatment andNormal Educational and Intellectual Functioningin Young Autistic Children; Journal ofConsulting and Clinical Psychology, 55(1), 3-9;American Psychological Association.

Ogletree, Billy. T and Oren, Thomas (2001).Application of ABA Principles to GeneralCommunication Instruction; Focus on Autismand Other Developmental Disabilities, 16(2),102-109.

Portney, L. G., & Watkins, M. P (2000). Foundationsof Clinical Research: Applications to Practice(2nd. Ed.) Upper Saddle River, New Jersey:Prentice Hall Health.

Rosenwasser, Beth and Axelrod, Saul (2001). TheContributions of Applied Behavioral Analysis tothe Education of People with Autism; BehaviorModification, 25(5), 671-677.

Sheinkopf, Stephen J. and Siegel, Bryna. (1998).Home-Based Behavioral Treatment of YoungChildren with Autism; Journal of Autism andDevelopmental Disorders, 28(1), 15-23

Smith, Tristram. (2001). Discrete-Trial Training inthe Treatment Of Autism; Focus on Autism andOther Developmental Disabilities, 16(2), 86-93.

Spreen, Otfried and Strauss, Esther. (1998). ACompendium Of Neuropsychological Tests,Administration, Norms and Commentary (2nd

Ed.). Oxford University Press.Weiss, Mary Jane.(1999) Differential Rates of Skill

Acquisition and Outcomes of Early IntensiveBehavioral Intervention for Autism; BehavioralInterventions, 14, 3-22.

50

Copyright © 2005, Gibson, K.L.

The effectiveness of linguistic specific treatmenton patients with agrammatic Broca’s aphasia

Gibson, K.L.M.Cl.Sc. (SLP) candidate


This critical review examines the effectiveness of Linguistic Specific Treatment (LST) amongpersons with agrammatic Broca’s aphasia. Studies employing single-subject multiple baselinedesigns were analyzed to determine the clinical effectiveness of LST. Overall, research supportsthe clinical effectiveness of LST in patients with agrammatic Broca’s aphasia; however, thetreatment is limited to those with mild to moderate aphasia and to specific sentence types.

Introduction

A common feature of patients with Broca’saphasia is the loss of grammatical structures inspeech, also known as agrammatism. These patientswill typically produce simple canonical (e.g subject-verb-object (SVO)) sentences, but not complex non-canonical sentences. Past treatment approaches havefocused on training patients on the production ofsimple sentence types and moving toward morecomplex sentences. These programs have shown tobe useful in improving sentence production inpatients with Broca’s aphasia; however, littlegeneralization is seen beyond the trained sentencetype. Linguistic Specific Treatment (LST) supportsthe treatment of more complex non-canonicalsentence forms, which will in turn allow for anincreased amount of generalization to other sentenceforms that have similar syntactic structure (Ballardand Thompson, 1999; Jacobs and Thompson, 2000;Thompson et al, 1997; Thompson et al, 1993)

LST is based on the theoretical framework thatpatients with Broca’s aphasia have difficulty inassigning thematic roles to verbs and processingsentences with moved constituents. The formation ofnon-canonical sentence types requires part of asentence (e.g. a noun phrase (NP)), to move from itsnormal position in the SVO structure to a newposition in the sentence (Ballard and Thompson,1999; Jacobs and Thompson, 2000; Thompson et al,1997; Thompson et al, 1993). When this occurs, atrace is left where the noun phrase has moved,forming a trace-antecedent chain (Ballard andThompson, 1999; Jacobs and Thompson, 2000;Thompson et al, 1997; Thompson et al, 1993). Thischain allows one to maintain the thematic roles of theNP in the non-canonical form. The movement of thesentence constituent (i.e. noun phrase) is called themove alpha (Thompson et al, 1997). Two types ofmovement have been studied in the literature inregards to the treatment of agrammatic speech.These are wh-movement and NP-movement

(Thompson et al, 1997). .In wh-movement, theconstituent is moved from an argument position (e.g.direct object position) to a non-argument position atthe beginning of the sentence (Ballard andThompson, 1999; Jacobs and Thompson, 2000;Thompson et al, 1997; Thompson et al, 1993). Forexample, changing the SVO sentence from, “The dogbit the cat’ to a ‘wh’ question form ,‘Who did the dogbite?’ requires movement of the direct object ‘cat’ tothe initial position in the form of ‘who’. ‘Cat’ nolonger holds the direct object position. In NP-movement, the noun phrase moves from an argumentposition (e.g. direct object) to another argumentposition (e.g. subject) (Ballard and Thompson, 1999;Jacobs and Thompson, 2000; Thompson et al, 1997;Thompson et al, 1993). For example, changing theSVO sentence, “The dog bit the cat” to the passiveform, “The cat was bit by the dog. The direct object‘cat’ moves to the subject position of the sentence. .

By increasing knowledge of thematic roles andtrace relations of moved constituents, there will beimproved sentence production for more sentencetypes. LST will in turn improve the informativenessand efficiency of the language production of patientswith aphasia (Ballard and Thompson, 1999; Jacobsand Thompson, 2000; Thompson et al, 1997;Thompson et al, 1993). Training one sentence typethat follows wh-movement rules will result inlearning of that sentence type as well as othersentence types that follow wh-movement rules. Thesame can be said of NP-movement rules. As a result,one will see greater generalization than previoustreatment approaches. If LST proves to be aneffective and more time-efficient treatment approachto agrammatism, it holds important clinicalimplications.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theeffectiveness of Linguistic Specific Treatment in

51

THE EFFECTIVENESS OF LINGUISTIC SPECIFIC TREATMENT ON PATIENTS WITH AGRAMMATIC BROCA’S APHASIA

treating agrammatism in patients with Broca’saphasia. The secondary objective is to propose anevidence-based practice recommendation aboutLinguistic Specific Treatment for patients withagrammatic Broca’s aphasia.

Methods


PubMed, and Cochrane Library, were searched usingthe following search strategy:

((Broca) OR (Broca’s)) AND (aphasia)AND ((agrammatism) OR (speech)).


review paper were required to investigate theimprovement in sentence production of patients withagrammatic Broca’s aphasia using LST. No limitswere set on the demographics of research participantsor outcome measures.

Data CollectionResults of the literature search yielded four

single-subject multiple baseline design studies.

Results

Sentence ProductionBallard and Thompson (1999) trained five

participants on wh-movement rules and testedgeneralization to other wh-movement sentences aswell NP-movement sentences. As predicted, all fivesubjects showed an improvement in production oftrained wh-movement sentences; however, only threeout of five subjects showed the predictedgeneralization to improvement to another wh-movement sentence.

Jacobs and Thompson (2000) trained subjects onthe production of wh-movement and NP-movementsentences. They did not assess whethergeneralization occurred to other sentence typessimilar in movement structures, but they looked atwhether training production would increasecomprehension and whether training comprehensionwould increase production. Two subjects weretrained on sentence production and showedimprovement for production of trained sentence typesbut not comprehension of these sentences. Two othersubjects were trained on comprehension and showedimprovement in comprehension and production oftrained sentence types.

In Thompson et al. (1997), two subjects weretrained on either wh-movement or NP-movementsentences. Subject 1 was trained on both wh-

movement and NP-movement rules. This resulted inimprovement for both trained and untrained sentencetypes, as expected for both movement types. Subject2 was only trained on NP-movement rules, as thesubject was already producing ‘wh’ questions duringbaseline testing. Improvement was seen for bothtrained and untrained sentence types, as predicted.

In Thompson et al. (1993), two subjects weretrained on the production of wh-questions. It waspredicted that by training one question, the subjectswould generalize to others. Subject 1 improved intrained ‘what’ questions but generalization was notseen to ‘who’ questions. Subject 2 showedimprovement in both trained ‘who’ questions anduntrained ‘what’ questions. Therefore, only 1 out of2 subjects showed the predicted generalization tountrained sentence types.

Overall, nine patients were trained on wh-movement rules and tested for generalization to othersentence types that followed wh-movement rules.Six of these patients showed improvement on trainedsentence types as well as generalization to othersentence types (Ballard and Thompson, 1999; Jacobsand Thompson, 2000; Thompson et al, 1997;Thompson et al, 1993). Therefore, six out of ninesubjects trained on wh-movement structuresgeneralized outside of the trained sentence. Twopatients were trained on NP-movement rules andtested for generalization to other sentence types.Both of these subjects improved in trained anduntrained sentence types using this treatment method(Ballard and Thompson, 1999; Jacobs andThompson, 2000; Thompson et al, 1997; Thompsonet al, 1993).

Impact on Discourse SkillsThe impact of LST on discourse skills is

important, as it demonstrates how effective LST isoutside of structured situations and provides furtherevidence of increased generalization. All of thesubjects that showed improvement in untrainedsentence production also showed improvement intheir discourse skills; however, changes wereminimal (Ballard and Thompson, 1999; Jacobs andThompson, 2000; Thompson et al, 1997; Thompsonet al, 1993). Improvement was noted by an increasein the number of correct information units (CIU) usedduring a narrative language sample as well as anincrease in the mean length of utterance. CIUs aredefined as a word that is accurate and informative forthe stimulus presented (Ballard and Thompson, 1999;Jacobs and Thompson, 2000; Thompson et al, 1997;Thompson et al, 1993) Therefore, LST can impacteveryday discourse skills; however, the extent ofimprovement needs further exploration.

52

THE EFFECTIVENESS OF LINGUISTIC SPECIFIC TREATMENT ON PATIENTS WITH AGRAMMATIC BROCA’S APHASIA

Conclusions

The studies reviewed indicate that LinguisticSpecific Treatment (LST) is an effective treatmentapproach for agrammatism in some patients withBroca’s aphasia. It is recommended that LST beconsidered as a treatment approach for patients withmild to moderate aphasia and when training wh-movement structures. LST is not recommended to beused as a proven treatment approach for all patientswith agrammatic aphasia, as the literature has toomany limitations.

Results have indicated that severity of aphasia isan important factor in the effectiveness of LST as atreatment approach. LST has resulted in improvedsentence production for trained and untrainedsentences as well as improve discourse skills inpatients with mild to moderate aphasia (Ballard andThompson, 1999; Jacobs and Thompson, 2000;Thompson et al, 1997; Thompson et al, 1993).Therefore, generalization was seen in these patientsbeyond the trained targets. The patients whodemonstrated more severe aphasia symptoms did notshow improvement in sentence production beyondthe specific trained sentence type or improveddiscourse skills (Ballard and Thompson, 1999; Jacobsand Thompson, 2000; Thompson et al, 1997;Thompson et al, 1993). These results indicate thatLST is only effective for patients with mild tomoderate Broca’s aphasia.

The number of subjects investigated using thisapproach within the literature is also of concern.Several subjects have proven the effectiveness ofLST when training the rules required for wh-movement structures; however, only two subjectshave been investigated when training NP-movementrules (Ballard and Thompson, 1999; Jacobs andThompson, 2000; Thompson et al, 1997; Thompsonet al, 1993). It is recommended that LST only beused to train wh-movement structures at this time.Further research is needed in training NP-movementrules before it should be recommended as a treatmentapproach. It is also recommended that when LST isused for training wh-movement structures, theclinician keep accurate and detailed records in orderto add to the existing literature.

Further, a formal comparison between LST andother treatment approaches has yet to be performed.To date, all studies completed have been single-subject designs (Ballard and Thompson, 1999; Jacobsand Thompson, 2000; Thompson et al, 1997;Thompson et al, 1993). The results can provideevidence that LST does cause an effect in patientswith agrammatic Broca’s aphasia, but cannotdemonstrate that it is more effective than otherproven treatments. It lies in the hand of the

practicing clinician to determine what treatmentapproach may be best for each individual client. Dueto the complex nature of LST, the clinician maychoose another treatment approach simply because itis easier to learn. LST, although useful and effective,is more complex than previous approaches used. LSTrequires effort and research on the clinician’s behalfto study the grammatical aspects of speech and learnhow these sentences are formed. In today’s busyworkplace, clinicians may not have the time neededto devote to learning this approach in order for it tobe implemented effectively.

Continued research is warranted to furtherinvestigate the effectiveness of LST; however, it isclear that LST has shown clinical improvements insome patients. It should be noted however, that thiscritique contained few articles and all articles werefrom the same group of authors. The use of LST as atreatment approach has important clinicalimplications. Any treatment approach that canprovide more time-efficient treatment and increasegeneralization is worth investigating. Furtherresearch should focus on increasing the sample sizeinvestigated, proving the effectiveness of LSTcompared to other treatment approaches andincreasing the amount of research by various authors.

References

Ballard, KJ, & Thompson, CK (1999). Treatmentand generalization of complex sentenceproduction in agrammatism. Journal of Speech,Language and Hearing Research, 42(3), 690-706.

Jacobs, BJ & Thompson, CK (2000). Cross-modalgeneralization effects of training noncanonicalsentence comprehension and production inagrammatic aphasia. Journal of Speech,Language and Hearing Research 43(1), 5-20.

Thompson, CK, Shapiro, LP, Ballard, KJ & Jacobs,BJ (1997). Training and generalized productionof wh- and NP-movement structures inagrammatic aphasia. Journal of Speech,Language and Hearing Research, 40(2), 228.

Thompson, CK, Shapiro, LP, & Roberts, MM (1993).Treatment of sentence production deficits inaphasia: a linguistic-specific approach to wh-interrogative training and generalization.Aphasiology 7 (1), 111-133.

53

Copyright © 2005, Grant, T.E.

Efficacy of the Fast ForWord-Language intervention program

Grant, T.E.M.Cl.Sc. (SLP) Candidate


This critical review examines the effects of treatment with Fast ForWord on the language skills ofchildren with language-learning impairments. Study designs include: one group pretest/posttest,pretest/posttest with control designs, case study, multi-probe single-subject, and longitudinal no-contact control. Overall, the research demonstrated that Fast ForWord may produce gains in someareas of language development but these gains are modest and may not be long-lasting. Given thehigh cost and considerable time involved in this program and given that other similar or lessintensive programs have yielded similar results, intervention with this program is not warranted.

Introduction

Fast ForWord (Fast ForWord-Language) is acomputer based language intervention programdeveloped by the Scientific Learning Corporation(Troia & Whitney, 2003). It is commerciallyavailable for a fee on the Internet using CD-ROMsoftware. The program is provided through certifiedproviders who have been trained in the program(Friel-Patti, Frome Loeb, & Gillam, 2001). Thisprogram is designed for children between 4 and 14years of age and training usually lasts 4-6 weeks(Troia & Whitney, 2003). Fast ForWord (FFW)provides training in auditory perceptual and spokenlanguage comprehension skills that are believed to becritical to communicative competence, andultimately, academic success. It has seven interactivegame-like activities to train verbal and nonverbalsound discrimination, vocabulary recognition, andlanguage comprehension (Troia & Whitney, 2003).Children receive feedback for correct and incorrectresponses after each trial (Friel-Patti et al., 2001).Therapy is intensive at approximately 1 hour and 40minutes a day. This program uses acousticallymodified stimuli that progress toward natural,unaltered speech. These training stimuli are used toaddress the presumed auditory temporal processingdeficits of at least some children with primarylanguage impairments and other types of language-based disabilities (Troia, & Whitney, 2003).

Since 1996, FFW has been delivered tothousands of children in public and private settings atthe cost of considerable time and money. Thedevelopers of FFW (Merzenich, Tallal and theircolleagues) have claimed that children withlanguage-learning impairments present gains of 1-11/2 years on standardized tests of language skillsafter 6 weeks of training. They attribute these gainsto improvements in the brain’s ability to representrapidly successive sounds with greater clarity andsharper distinctions (Gillam, Frome Loeb, & Friel-

Patti, 2001). It has been hypothesized that one causeof children’s language disorders is poor temporalprocessing (Troia, & Whitney, 2003). The FFWprogram was designed on the assumption that thishypothesis is true, however a great deal ofcontroversy surrounds this topic and the debate is farfrom being resolved. However, it is still possible thatFFW could be an effective intervention regardless ofthe true nature of the difficulties of children withlanguage impairments and reading problems (Troia,& Whitney, 2003).

Given the high cost and time commitmentinvolved in implementing the FFW program, areview of the literature was conducted in order todetermine if there is evidence to support treatingchildren with FFW. It is important to determine iftreatment with FFW (or any particular intervention)is warranted. As professionals, Speech-LanguagePathologists (SLPs) have an obligation to providetheir clients with interventions that have evidence tosupport their use in order to ensure their clients aregetting the best possible service.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theimpact of FFW training on the language skills ofchildren with language-learning impairments. Thesecondary objective is to propose evidence-basedpractice recommendations for SLPs concerningimplementation of the FFW program.

Methods

Search StrategyComputerized databases, including PsycINFO

and PubMed, were searched using the followingsearch strategy:

(Fast ForWord) AND (intervention) OR(language).

54

EFFICACY OF THE FAST FORWORD-LANGUAGE INTERVENTION PROGRAM



review paper were required to investigate the impactof the FFW program on the language skills ofchildren with primary language impairments andother types of language-based disabilities. No limitswere set on the demographics of research participantsor outcome measures.


following types of articles congruent with theaforementioned selection criteria: one grouppretest/posttest (1), pretest/posttest with controldesigns (2), case study (1), multi-probe single-subject(1), and longitudinal no-contact control (1).

Results

Impact of FFW on Language Skills

Verbal and Nonverbal Sound DiscriminationAccording to the studies conducted by the

developers of the FFW program, children withlanguage-learning impairments demonstratedsignificant improvements (p<.05) on norm-referencedtests of speech discrimination following interventionwith FFW (Tallal, Miller, Bedi, Byma, Wang,Nagarajan, Schreiner, Jenkins & Merzenich, 1996).Moreover, children in the experimental treatmentcondition displayed significant gains (p<.05) innonverbal auditory sequential perception, whereasthose in the comparison treatment did not (Tallal etal., 1996).

In addition to the studies conducted by thedevelopers of FFW, several other investigations havebeen conducted. Frome Loeb, D., Stoke, C. and Fey,M. (2001) used a case study design to examine theeffectiveness of FFW outside experimental settings.Three of the four children completed the FFWprogram successfully in their homes with theirparents serving as monitors, and all made gains onsome of the same standardized measures used byTallal et al. (1996). Frome Loeb et al. (2001)revealed that the improvements observed weregenerally smaller than those previously reported byTallal et al. (1996) and may not be long lasting.

Hook, Macaruso and Jones (2001) reported thatstudents who had been treated with FFW madesignificant but similar gains (p<.05) in phonologicalawareness and reading to a similar intervention, theOrton-Gillingham (OG) multisensory alphabetictraining program, suggesting that other similar

interventions may produce outcomes comparable tothose of the FFW program.

Expressive Oral LanguageGillam, Crofford, Gale and Hoffman (2001)

determined that FFW led to observableimprovements in spontaneous language. Theycompared the FFW program to a bundle ofintervention programs published by LaureateLearning Systems (LLS) and reported strikinglysimilar gains between the two programs. Theysuggested that these similar gains may suggest thatFFW is no more effective than other computerizedintervention programs. According to the study byGillam et al. (2001), all four participants in theirstudy made significant gains on standardized tests ofexpressive language regardless of the intervention(FFW or bundle by LLS). Gains were also made interms of increased mean length of utterance (MLU)for two of the children who received the LLSsoftware and one who received FFW (Gillam et al.,2001).

Troia and Whitney (2003) reported that exceptfor performance on a measure of expressive orallanguage, on which the children in the control groupachieved significantly greater gains (p<.05) thanthose in the control group, changes in test scoresfrom pretest to posttest were equivalent for the twogroups. However, they suggested that when justcomparing the lowest performing students, thetreatment group demonstrated superior gains inexpressive oral language, syllable and soundblending, and a reduction in problem behaviours(Troia & Whitney, 2003).

Language ComprehensionTallal et al. (1996) reported that as a group,

performance on norm-referenced tests of languagecomprehension improved significantly (p<.05).

The study by Gillam, Crofford, Gale andHoffman (2001) revealed that all four participants intheir study (two who received FFW and two whoreceived the bundle by LLS) made significant gainson standardized tests of receptive language.

PragmaticsAccording to the study by Frome Loeb et al.

(2001), all children made gains on measures ofpragmatic performance following intervention withFFW.

Conclusions

According to the available literature, FFW mayproduce gains in some areas of languagedevelopment but these gains are modest and may not

55

EFFICACY OF THE FAST FORWORD-LANGUAGE INTERVENTION PROGRAM

be maintained over time. The gains are certainly notas promising as those originally proposed by thedevelopers of the FFW program.

Of the articles reviewed, all reported thatintervention with the FFW program resulted in somegains in the language skills of children with languageimpairments. However, with the exception of thedevelopers of the FFW program, who reportedsubstantial improvements, all of the other studiesreported modest gains that may not be long lasting.Furthermore, two of the studies suggested that similaror less intensive programs have yielded similarresults to FFW. After reviewing the availableliterature in this area, it is clear that the FFW programresulted in modest improvements at best in thelanguage skills of children with language-learningimpairments.

Although all of the studies did report at leastminimal gains, treatment with the FFW program isnot recommended by this author for a few reasons.First of all, it is a very costly program to administer.The program itself costs about nine hundred dollarsplus the cost of administration by SLPs. Secondly,therapy is intensive at one hour and forty minutes aday, which is a considerable time commitment,especially for younger children and those who havelower attention spans. Thirdly, most studiessuggested that the FFW program resulted in onlyminimal gains and that these gains may not bemaintained. Finally, two of the studies reportedsimilar gains following intervention with similar orless intensive computer intervention programs.

Many of these study findings have yet to besubjected to the scrutiny of the research communitythrough peer review or independent replication. Fewexperimentally controlled studies of the efficacy ofFFW training have been conducted and a large-scaleclinical trial is recommended to fill the current gap inthe literature and serve to determine with clinicalsignificance the efficacy of the FFW program. Giventhe limitations of the FFW program discussed above,this program should not be recommended by SLPsunless it is proven with clinical significance in thefuture to be an effective intervention.

References

Friel-Patti, S., Frome Loeb, D. & Gillam, R.(2001).Looking ahead: An introduction to fiveexploratory studies of Fast ForWord. AmericanJournal of Speech-Language Pathology, 10, 195-203.

Frome Loeb, D., Stoke, C. & Fey, M. (2001).Language changes associated with FastForWord-language: Evidence from case studies.

American Journal of Speech-LanguagePathology, 10, 216-231.

Gillam, R., Crofford, J. & Gale, M. (2001). Languagechange following computer-assisted languageinstruction Fast ForWord or Laureate LearningSystems software. American Journal of Speech-Language Pathology, 10, 231-248.

Gillam, R., Frome Loeb, D. & Friel-Patti, S. (2001).Looking back: A summary of five exploratorystudies of Fast ForWord. American Journal ofSpeech-Language Pathology, 10, 269-274.

Hook, P., Macaruso, P. & Jones, S. (2001). Efficacyof Fast ForWord training on facilitatingacquisition of reading skills by children withreading difficulties — a longitudinal study.Annals of Dyslexia, 51, 75-97.

Tallal, P., Miller, S., Bedi, G. Byma, G., Wang, X.,Nagarajan, S., Schreiner, C., Jenkins, W., &Merzenich, M. (1996). Language comprehensionin language-learning impaired children improvedwith acoustically modified speech. Science, 271,

81-84.Troia, G. & Whitney, S. (2003). A close look at the

efficacy of Fast ForWord Language for childrenwith academic weakness. ContemporaryEducational Psychology, 28, 465-494.

56

Copyright © 2005, Green, J.L

Efficacy of melodic intonation therapy to increase functional communicationin adults with nonverbal aphasia.

Green, J.L.M.Cl.Sc. (SLP) Candidate


This critical review examines the efficacy of Melodic Intonation Therapy (MIT) in increasingfunctional communication for people with nonverbal aphasia. Study designs include: single-subject pre-test, post-test designs and a case study. Overall, the research does not strongly supportthe use of MIT to increase functional communication; however, results have been shown toincrease verbal productions in a clinical setting and future research is still needed.

Introduction

Aphasia is an impairment in language that resultsfrom damage to the brain caused by injury or disease.It occurs most often as a consequence of a cerebralvascular accident (CVA) or stroke. “It ischaracterized by reduction in or an impaired ability toaccess language content or meaning, language formor function, and the cognitive processes that underlieand interact with language” (Chapey and Murray,2001, p55). Speech and language are lateralizedprimarily in the left hemisphere; therefore, when aninterruption to blood flow occurs in the lefthemisphere, speech and language are susceptible tobecome disordered. One pattern of disorder that canoccur is a difficulty with expression which is alsoknown as nonverbal aphasia, where a patient hasdifficulty speaking.

Melodic Intonation Therapy (MIT) wasoriginally introduced in 1973 (Sparks, 1973). It wasformulated from the basic observation that peoplewith aphasia due to left hemisphere strokes havehistorically been able to sing even though they maynot be able to speak. Interestingly, musical tonalability is a function found in the right hemisphere(Benson, 1994). Therefore, Sparks (1973) proposedthe use of the unimpaired right hemisphere tointroduce new pathways into damaged areas of theleft hemisphere through the use of the musicalaspects of language, namely prosody and intonation.

Sparks et al. (1974) developed a specified multi-level program to follow for the use of MIT. In thisprogram, short phrases are embedded into simplemelody patterns (Albert, 1973). There is a strictcriteria for patient selection which has beendeveloped through various research studies showingboth the ineffectiveness with certain patients and theeffectiveness with others (Berlin 1996). Patientsreported to have the most success with MIT hadsevere nonverbal expression difficulties with normal-mild auditory comprehension (Sparks, 1974).

Sparks states that the goal of MIT is the “basicrecovery of (the) ability to use some languageaccurately” (2001, p. 703) and in 1974, he reportedthat MIT results in “recovery of some propositionallanguage”(p. 303). Laughlin et al. also report that the“goal of MIT is to facilitate formulation ofpropositional language” (1979, P. 319). Therefore,the proposed goals of MIT can be linked to having aneffect on increasing a patient’s verbal competence incommunication, particularly increasing thefunctionality of patient’s communication.

Over the course of the last 30 years, studies havebeen completed worldwide on the use of MIT invarious languages such as Romanian, Japanese andFrench. (Popovici et al., 1992; Seki K, SugishitaM,1983; Van Eeckhout et al., 1982) Studies havealso been done to examine the brain after successfulor non successful melodic intonation therapy withPET and CT scans (Berlin, 1996; Naeser & Helm-Estabrooks, 1985).

Objectives

The primary objective of this paper is tocritically evaluate the literature regarding the efficacyof MIT in increasing functional communication forpeople with nonverbal aphasia. This literature has notbeen critically appraised for its efficacy and it isuncertain as to whether functional outcomes arebeing measured. The secondary objective is to beable to provide evidence based recommendationsregarding the use of MIT with nonverbal aphasics.

Methods

Search StrategyComputerized databases, including PubMed,

PsychInfo, Combined Health Information Database(CHID) online, Cochrane Library, Proquest andMedline- OVID were searched using the followingsearch strategy:

57

EFFICACY OF MELODIC INTONATION THERAPY TO INCREASE FUNCTIONAL COMMUNICATION IN ADULTS WITH NONVERBAL APHASIA

Melodic Intonation therapy) OR (MIT)AND (aphasia) OR (aphasia rehabilitation)OR (adults).

The search was limited to English languagearticles.

Selection CriteriaStudies selected for inclusion in this review were

studies that investigated the MIT technique with adultnonverbal aphasics to increase functionalcommunication or studies examining the MITtechnique versus regular speech.

Data CollectionThe literature search found the following studies

examining treatment outcomes: case study (1) andsingle subject designs (3). Other types of studiesfound: retrospective (2).

Results

Increasing verbal expression using MITAlbert et al. (1973) provided examples of three

patients that had undergone MIT after achievinglimited success in language therapy over a period oftwo to three months. The researchers reportedanecdotal evidence of success in those three patients.The most common finding was an increase inmeaningful propositional speech. The authorsmeasured treatment outcome with observation andthis could have caused the results to be biased. Also acase study does not have controls and therefore, thislimits the ability to draw conclusions from the reportsand to generalize.

Sparks et al. studied the use of MIT with eight,right-handed severely nonverbal adults with lefthemisphere aphasia. The authors concluded that sixof the eight patients had shown “recovery of someappropriate propositional language” (1974, p. 314).The results of the statistical analysis of these sixpatients found significant results for three verbal testsin the Boston Diagnostic Aphasic Examination(BDAE); the most significant result occurred in anincrease in phrase length (p<0.003). There was also avisual analysis of pre- and post-test scores thatshowed improvements in the subjects test scores.This study contains various methodological flaws. Interms of design, this study did not have a controlgroup to be able to eliminate the important factor oftime spent in therapy. The subjects were notrandomly selected and they did not control for anysubject variables. Consequently these flaws decreasethe validity and reliability of the study. Also thesubject size was small and therefore, limits thegeneralizability of the results. An advantage of thisstudy was the use of a standardized test to measure

outcomes. When looking at the results the authorsobtained, it is important to note that the results werepresented in an unclear manner, some data wasunaccounted for and inappropriate statistical testswere used for the nature of the design. Therefore,caution needs to be taken when interpreting theseresults.

MIT vs regular speechThe 1979 study by Laughlin and Naeser

examined three syllable durations: regular speech,MIT with a 1.5 sec. duration, and MIT with a 2.0 sec.duration. They studied the use of MIT to increasephrase production with five adults with nonverbalaphasia. The researchers hypothesized that prolongedsyllable durations would improve the subjects’ verbalperformances within the MIT technique. Theyobserved successful results when looking at meansacross conditions and they also performed statisticalanalyses and found statistically significant results toshow that phrase production was significantlyaffected by the syllable duration (p<0.001). They alsofound that there was a significant interaction betweensyllable duration and MIT step (p<0.001). Overallboth syllable durations in MIT were significantlybetter than regular speech (duration 1.5 sec. p<0.005and duration 2.0 sec. p<0.001). Therefore, theseresults were able to demonstrate that the patients hadmore success with the MIT technique Vs regularspeech. In terms of methodology, this study lacked acontrol group, it had a small sample size with norandom selection. These factors limit the validity andgeneralizability of this study. The researchersreported some subject variables but they did notcontrol for these variables; therefore, there may havebeen confounding effects. In terms of collected data,they had a lot of data points which adds reliability tothe outcomes. In terms of the results they found, thestatistical tests they employed were appropriate forthe type of data collected; however the power of thetests was limited because a parametric test was usedfor non-parametric data. Overall this study had astronger methodology than the other studies lookedat; unfortunately, this study only examines thedifference between using MIT and regular speech itdoes not examine using MIT as a treatment foraphasia. Therefore, the usefulness of this study islimited when looking at the question stated above.

MIT vs regular speech and increasing verbalexpression using MIT

Goldfarb and Bader (1979) examined the use ofMIT with a 50- year old man with severe languagedeficits due to two left hemispheric strokes. Thispatient had shown little progress in language therapy.MIT was administered both in the clinic and at home.

58


The authors demonstrated success with the MITprogram using descriptive statistics. They showed anincrease in the patient’s ability to imitate. They alsodemonstrated that scores acheived through MIT wereconsistently higher than normal speech scores. Theauthors cautioned the effectiveness of MIT inenvironments outside the clinic. This study did notcontrol for amount of time spent in treatment andtherefore, it cannot be ruled out that any treatmentprovided with this intensity and frequency would nothave had similar results. The generalizability of theresults is low because there was no replicability dueto the subject size. It was an advantage that theresearchers administered pre-treatment measures thatwere standardized; however, unfortunately they didnot re-administer these tests post-treatment. Also thestimuli that was used for pre-treatment baselines wasalso the stimuli used during treatment and for post-treatment results. There was no report on how thestimuli were developed or their psychometricproperties. This lack of reliability or validity in theoutcome measures causes uncertainty in the overallvalidity and reliability of the results. The results weredescriptive therefore no interpretation about thegeneralizability of the results can be obtained.Clinical significance was demonstrated becauseprogress across the treatment time was shown in theclinic; however this study is limited in determiningfunctional communication gain because of theartificial circumstances in which it was studied.

Conclusions

Consequently, even though two of the studies foundstatistical significance and three studies demonstratedclinical significance, a strong recommendationcannot be made to support the use of MIT to increasefunctional communication. This conclusion is basedon the observation that there were consistentlimitations throughout the studies and theselimitations were significant enough to have a majorimpact on the findings. The most common limitationwas the lack of validity and reliability in themethodology and outcome measures. This impactsthe generalizability of the results to the aphasicpopulation. This is a serious flaw and limits aclinicians confidence in using the technique with herpatients to increase functional communication.Furthermore, the lack of current published researchfor this technique also causes doubt about the currentclinical relevance of this technique.Sufficient evidence was not found for the carryoverof the results to functional communication situations;therefore, a recommendation cannot be made for MITbeing an efficacious treatment to increase functionalcommunication in adults with nonverbal aphasia.

Considering the evidence in these four articles, MITcan show change in clinical settings by increasingverbal output for adults with expression difficultiesthat only have mild to moderate comprehensiondifficulties. More studies demonstrating transfer ofincreased verbal output to everyday communicationsetting would increase the reliability andgeneralizability of this technique. Additionally,studies that have control subjects and control forconfounding variables would be better able to ruleout confounding effects. Current therapy has seen anincrease in the importance and significance ofincorporating functional communication intolanguage therapy goals. Therefore, if clinical andstatistical results can be shown to have functionalcommunication value then MIT may have promisefor adults presenting with severe nonverbal aphasiawith mild to moderate comprehension difficulties.

References

Albert, M.L., Sparks, R.W., & Helm, N.A. (1973).Melodic intonation therapy for aphasia. Archivesof Neurology. Aug;29(2), 130-1.

Benson, F., Dobkin, B., & Gonzalez, L. (1994).Assessment: Melodic intonation therapy. Reportof the Therapeutics and Technology AssessmentSubcommittee of the American Academy ofNeurology. Neurology, 44, 566-8.

Berlin et al. (1996). Recovery from non fluentaphasia after melodic intonation therapy: a PETstudy. Neurology, 47(6), 1504-11

Berlin, C.I. (1976). On: melodic intonation therapyfor aphasia by R.W.Sparks and A.L.Holland.Journal of Speech and Hearing Disorders, 41(3),298-300.

Brookshire, R. (2003). Introduction to NeurogenicCommunication Disorders (6th ed). St. Louis,MO: Mosby.

Chapey, R. & Murray, L. (2001). Assessment ofLanguage Disorders in Adults. In R. Chapey(ed.), Language Intervention Strategies inAphasia and Related NeurogenicCommunication Disorders (4th ed), 703-717.Baltimore, Maryland: Lippincott, Williams, &Williams.

Goldfarb, R. & Bader, E. (1979). Espousing melodicintonation therapy in aphasia rehabilitation: Acase study. International Journal ofRehabilitation Research, 2(3), 333-342.

Naeser, M.A. & Helm-Estabrooks, N. (1985). CTscan lesion localization and response to melodicintonation therapy with non fluent aphasia cases.Cortex, 21(2), 203-23.

Popovici, M., Mihailescu, L. (1992). MelodicIntonation in the rehabilitation of Romanian

59


aphasics with bucco-lingual apraxia. Review ofRomanian Neurological Psychiatry; 30, 99-113.

Seki, K., Sugishita, M. (1983). Japanese-appliedmelodic intonation therapy for Broca aphasia. NoTo Shinkei, 35(10), 1031-7.

Sparks, R.W., Holland, A.L. (1976). Method:melodic intonation therapy for aphasia. Journalof Speech and Hearing Disorders, 41(3), 287-97.

Sparks, R., Helm, N., Albert, M. (1974). Aphasiarehabilitation resulting from melodic intonationtherapy. Cortex, 10(4), 303-16.

Sparks, R. (2001). Melodic Intonation Therapy. In R.Chapey (ed), Language Intervention Strategiesin Aphasia and Related NeurogenicCommunication Disorders (4th ed), 703-717.Baltimore, Maryland: Lippincott, Williams, &Williams.

Van Eeckhout, P. et al. (1982). Reduction desreductions severe de l’expression orale: la“therapie melodic et rythmee.” In Mardaga P.(ed) Reeduquer le cerveau. Bruxelles: Soledi,109-121.

60

Copyright © 2005, Harty, J.D.

The role of dysphagia and prandial aspirationas predictors of aspiration pneumonia

Harty, J.D.M.Cl.Sc. (SLP) Candidate


This critical review examines the role of dysphagia and prandial aspiration as key predictors ofaspiration pneumonia. Overall, research supports a relationship among these three variables.However, other predisposing conditions have also been identified. Because aspiration pneumoniaappears to be a multi-factorial phenomenon, an effective management strategy should consider allrelevant risk factors.

Introduction

Aspiration pneumonia is an inflammation of thelungs and bronchial tubes that is caused by theinhalation of foreign material, such as food or drink,from the mouth into the lungs (Tomblin, 2000).Many predisposing conditions have been cited in theliterature including reduced levels of consciousness,gastric reflux, tube feeding and altered neurologicalstatus (Teasell et. al, 1996). Although dysphagia haslong been recognized as a risk factor for aspiration,the relationship between dysphagia and thedevelopment of aspiration pneumonia is less clear.

The impact of aspiration pneumonia iswidespread. The nature of this condition is relevantto many health care professionals including primarycare physicians, nurses, speech languagepathologists, clinical dieticians, respiratory therapistsand physiotherapists. Therefore, the professionalsworking directly with this population need evidenceto guide their clinical management decisions. The‘greying’ of the population has also providedmotivation to identify the risk factors associated withaspiration pneumonia (Marik & Kaplan, 2003).Preventative initiatives are becoming increasinglyimportant. Another driving force behind thisinvestigation is the movement away from thetraditional medical model of health. Health careprofessionals are no longer motivated to simply treatsymptoms and eradicate disease. They are alsointerested in improving the quality of their patients’lives. Therefore, if a relationship between dysphagiaand the development of aspiration pneumonia cannotbe consistently established in the literature, theconventional measures of withholding oral feedingsand modifying a patient’s diet are questionable.

It is obvious that aspiration pneumonia places anenormous burden on the health care system in termsof morbidity, mortality and expenditure. However,some controversy remains regarding its etiology.Predictors that warrant further investigation includeprandial aspiration and dysphagia.

Objectives

The primary objective of this paper is tocritically evaluate the existing literature regarding therelationship between prandial aspiration, dysphagiaand the development of aspiration pneumonia. Thesecondary objective is to propose evidence-basedpractice recommendations with regards to theprevention of aspiration pneumonia.

Methods

Search StrategyA computerized database (PubMed) was

searched using the following strategy:(Aspiration pneumonia) OR (Pneumonia)AND (risk factors) OR (predictors) OR(dysphagia) OR (swallowing impairment)OR (Deglutition disorder) OR (swallowingdisorder) OR (aspiration)

Selection Criteria The search was limited to articles written in

English between 1994 and 2004. No limits were seton the demographics of research participants oroutcome measures. Studies selected for inclusion inthis critical review paper were required to investigateprandial aspiration and/or dysphagia and pneumoniadevelopment.

Research DesignAll of the studies obtained through this literature

search were quasi-experimental and best classified aseither case-control (prospective) or cohort(retrospective) studies. Most of the studies used largesamples obtained via convenience sampling in eitherlong-term care facilities, outpatient clinics or variousinpatient acute care wards. Due to inconsistentinclusion/exclusion criteria, participants had variousdifferent underlying medical conditions (i.e.- stroke,dementia, Parkinson’s Disease etc.) and represented awide age range (i.e.- 19 – 99 years).

61

THE ROLE OF DYSPHAGIA AND PRANDIAL ASPIRATION AS PREDICTORS OF ASPIRATION PNEUMONIA

In most cases, baseline measures were obtainedthrough Modified Barium Swallow studies,observation and/or via chart reviews. Outcomemeasures typically included a combination ofqualitative (i.e.- chest pain) and quantitative (i.e.-chest x-rays) indicators of pneumonia. All of theresearchers reported associations after conductingcorrelation and/or multiple regression analyses.

Overall, external validity for this subset of theliterature is satisfactory when the studies are viewedas a whole rather than individually. This is becausethe samples included different populations (i.e.-medical conditions, age groups) obtained fromvarious different settings (i.e.- nursing homes etc.).However, the lack of a consistent operationaldefinition of aspiration pneumonia is an inherentlimitation of this subset of the literature. In addition,the use of informal assessments to obtain baselineinformation in some studies is potentiallyproblematic due to the possibility of silent aspirationand other swallowing disturbances that cannot bereadily observed.

Results

Supporting EvidenceOverall, the supporting evidence is based on

sound methodology and appropriate statisticalanalyses. Many of the studies used large samples andprospective research designs.

Prandial Aspiration/DysphagiaAfter conducting bivariate analyses, Teasell and

colleagues (1996) reported that individuals whoaspirated were significantly more likely to developpneumonia than individuals who did not aspirate.

Several other groups of researchers investigatedthe relative importance of multiple predictors ofpneumonia by conducting multivariate analyses.Vergis and colleagues (2001) reported that witnessedaspiration was independently and significantlyassociated with pneumonia frequency. In addition,both Loeb and colleagues (1999) and Langemore andcolleagues (2002) found that dysphagia was asignificant and unique predictor of pneumonia.

Degree of Swallowing ImpairmentPikus and colleagues (2003) reported that the

likelihood of developing pneumonia was directlyrelated to the degree of dysphagia. Individuals withno laryngeal penetration, regardless of whether theyhad normal or abnormal swallowing, had the lowestrisk of developing pneumonia. Individuals withlaryngeal penetration were at a significantly higherrisk and individuals with tracehobronchial aspiration

were at an even greater risk for developingpneumonia.

Bolus VolumeHolas and colleagues (1994) found that

individuals who aspirated more than 10% of thebolus had an increased likelihood of developingpneumonia. However, Schmidt and colleagues(1994) did not find a significant relationship withregards to bolus volume and pneumonia risk.

Silent AspirationBoth Holas and colleagues (1994) and Pikus and

colleagues (2003) reported that silent aspirators weresignificantly more likely to develop pneumonia thanindividuals who aspirated overtly (Holas et. al, 1994& Pikus et. al, 2003).

Bolus ConsistencyLangemore and colleagues (1998) found that

aspirated solids were more significantly associatedwith pneumonia frequency than aspirated liquids.Schmidt and colleagues (1994) also reported thatindividuals who aspirated thick liquids and/or solidshad an increased risk of developing pneumonia whencompared to individuals who aspirated thin liquidsonly. Although this finding just fell short of reachingstatistical significance (p = 0.06), Schmidt andcolleagues (1994) suggested that this was a reflectionof their small sample size.

Disputing Evidence

Bivariate AnalysesBoth Croghan and colleagues (1994) and

Feinberg and colleagues (1996) concluded thataspiration did not accurately identify individuals at anincreased risk for developing pneumonia. However,Croghan and colleagues (1994) conducted a poweranalysis and reported that the number of participantsin their study was too small to detect all statisticallysignificant differences. In addition, Feinberg andcolleagues (1996) only investigated the relationshipbetween aspiration of liquids and the development ofpneumonia. Therefore, the conclusions based onboth studies are inherently limited.

Multivariate AnalysesLangemore and colleagues (1998) and Riquelme

and colleagues (1996) found that dysphagia was asignificant predictor of pneumonia according tobivariate analyses. However, both groups ofresearchers reported that dysphagia was not a uniqueand significant predictor of pneumonia afterconducting multivariate analyses. Langemore andcolleagues (1998) stressed that the results do not

62


necessarily imply that dysphagia and prandialaspiration are not important predictors. Theysuggested that dysphagia and prandial aspiration arehighly correlated with other risk factors that hadbetter predictive value (i.e.- dependence for feeding).

Other Relevant PredictorsSeveral groups of researchers investigated

multiple predictors of aspiration pneumonia.Although the results varied from study to study,several key predictors emerged. Variables that weresignificantly associated with aspiration pneumonia atthe multivariate level included (but are not limited to)dependence for feeding, dependence for oral care,number of decayed teeth, number of medications andmobility status (Langemore et. al, 1998, Langemoreet. al, 2002 & Vergis et. al, 2001).

Recommendations

Aspiration Pneumonia PreventionBased on the findings from the reviewed studies,

it appears that no single predictor (includingdysphagia) causes aspiration pneumonia by itself.Likewise, no single strategy will likely prevent thisdisease. Therefore, any initiative designed to preventaspiration pneumonia must focus on all relevant riskfactors (Langemore et. al, 1998). Althoughtraditional swallowing therapy (i.e.- dietmodifications, compensatory maneuvers and posturaladjustments) is crucial, the evidence suggests that aneffective intervention program must go beyond thedirect treatment of the swallow (Langemore et. al,1998).

Feeding ProgramsMany individuals who cannot feed themselves

are often fed by untrained personnel who do notunderstand dysphagia and are under time pressure tofeed as many patients as they can in a short period oftime (Langemore et. al, 1998). Therefore, it isimperative that nurses, volunteers and familymembers receive adequate training with regards tosafe feeding techniques. More efficacy studies arealso needed to promote widespread adoption of thesetraining programs.

Oral HygieneIt is essential to evaluate oral hygiene in all

patients with dysphagia on a regular basis regardlessof dental status. Regular tooth brushing in dentatepatients and regular cleaning of the oropharynx withantiseptic mouthwash in edentate patients are twoessential measures (Oh et. al, 2004). Because manyindividuals cannot maintain oral hygiene

independently, training and support must be providedto nurses, volunteers and caregivers.

MedicationsIt is imperative that speech language pathologists

carefully review each patient’s medication list whenplanning intervention. If it is determined that apatient is taking medications that reduce salivaryflow, medications that have a sedative effect, and/ora large quantity of medications, the speech languagepathologist should consult with the attendingphysician immediately. In some cases, the physicianmay be able to prescribe alternatives and/or reducethe total number of medications taken by the patient(Langemore et. al, 1998). In-service educationopportunities provided by the speech languagepathologist to physicians, residents and nurses mayincrease awareness and promote more teamcollaboration within this area.

Mobility and IndependenceSpeech language pathologists should work

closely with other team members (i.e.-physiotherapists, occupational therapists andrecreational therapists) to encourage increased patientmobility in order to facilitate pulmonary clearanceand increase the patient’s immune defenses. It is alsoessential to work closely with these professionals(particularly occupational therapists) to promote andsupport the patient’s independence in terms ofactivities of daily living (i.e.- feeding and oralhygiene).

Instrumental AssessmentsSilent aspiration and bolus volume are two

important factors to consider when determining apatient’s risk of developing aspiration pneumonia.These findings underscore the value of instrumentalassessment tools such as Modified Barium Swallowstudies. Clinical bedside evaluations do not providesufficient information with regards to these twopredisposing factors.

Conclusions

Despite some variability in the literature,research has demonstrated that individuals withdysphagia are at an increased risk of developingpneumonia. Research has also confirmed thataspiration pneumonia is a multi-faceted problem.Therefore, it is imperative to consider theindividual’s functional status (i.e.- mobility), medicalstatus (i.e.- medications), dental status (i.e.- oralhygiene) and swallowing status (i.e.- silentaspiration) when planning intervention.

63


Future studies in this area should utilizeprospective research designs and sample sizes shouldbe determined via power analysis. In addition,baseline measures should be obtained viainstrumental assessment tools and outcome measuresshould reflect a consistent definition of aspirationpneumonia. Additional studies that extend thecurrent knowledge base by investigating theinteraction of several known risk factors would beinvaluable. In addition, more studies are needed toevaluate the efficacy of various combinedmanagement approaches.

Although it is impossible to completely preventaspiration pneumonia, the application of combinedintervention strategies could potentially make adifference for both society and the individualsdirectly affected.

References

Croghan, J., Burke, E., Caplan, S., & Denman, S.(1994). Pilot study of 12-month outcomes ofnursing home patients with aspiration onvideofluoroscopy. Dysphagia, 9, 141-146.

Feinberg, M., Knebl, J., & Tully, J. (1996). Prandialaspiration and pneumonia in an elderlypopulation followed over 3 years. Dysphagia,11, 104-109.

Holas, M., DePippo, K., & Reding, M. (1994).Aspiration and relative risk of medicalcomplications following stroke. Archives ofNeurology, 51 (10), 1051-1053.

Langemore, S., Terpenning, M., Schork, A., Chen,Y., Murray, J., Lopatin, D., & Loesche, W.(1998). Predictors of aspiration pneumonia: Howimportant is dysphagia? Dysphagia, 13, 69-81.

Langemore, S., Skarupski, K., Park, P., & Fries, B.(2002). Predictors of aspiration pneumonia innursing home residents. Dysphagia, 17 (4), 298-307.

Loeb, M., McGreer, A., McArthur, M., Walter, S., &Simor, A. (1999). Risk factors for pneumoniaand other lower respiratory tract infections inelderly residents of long-term care facilities.Archives of Internal Medicine, 159, 2058-2064.

Marik., P., & Kaplan, D. (2003). Aspirationpneumonia and dysphagia in the elderly. Chest,124, 328-336.

Oh, E., Weintraub, N., & Dhanani, S. (2004). Can weprevent aspiration pneumonia in the nursinghome? Journal of the American MedicalDirectors Association, 5, 174-179.

Pikus, L., Levine, M., Yang, Y., Rubersin, S.,Katzka, D., Laufer, I., & Gefter, W. (2003).Videofluoroscopic studies of swallowingdysfunction and the relative risk of pneumonia.

American Journal of Roentgenology, 180, 1613-1616.

Riquelme, R., Torres, A., El-Ebiary, M., De LaBellacasa, J., Estruch, R., Mensa, J., Fernandez-Sola, J., Hernandez, C., & Rodriguez-Roisin, R.(1996). Community-acquired pneumonia in theelderly: A multivariate analysis of risk andprognostic factors. American Journal ofRespiratory and Critical Care Medicine, 154,1450-1455.

Schmidt, J., Holas, M., Halvorson, K., & Reding, M.(1994). Videofluoroscopic evidence of aspirationpredicts pneumonia and death but notdehydration following stroke. Dysphagia, 9, 7-11.

Teasell, R., McRae, M., Marchuk, Y., & Finestone,H. (1996). Pneumonia associated with aspirationfollowing stroke. Archives of Physical Medicineand Rehabilitation, 77, 707-709.

Vergis, E., Brennen, C., Wagener, M., & Muder, R.(2001). Pneumonia in long-term care. Archivesof Internal Medicine, 161, 2378-2381.

64

Copyright © 2005, Heals, A.

Is gastrostomy a safe feeding alternativefor children with neurodevelopmental disabilities?

Heals, A.M.Cl.Sc. (SLP) Candidate


This critical review examines the effects of gastrostomy-tube (G-tube) feeding on children withneurodevelopmental disabilities. Study designs include: quasi-experimental designs andobservational studies. The results of this review illustrate that there is little consensus on theappropriateness of G-tube feeding with this population. Overall, the literature indicates thatgastrostomy does not prevent aspiration pneumonia in individuals with neurodevelopmentaldisabilities. Additionally, G-tube feeding may cause or exacerbate gastroesophageal reflux (GER)in these children. The possibility that G-tube feeding is associated with excess mortality inchildren with neurodevelopmental disabilities is also implicated.

Introduction

Children with neurodevelopmental disabilities,such as cerebral palsy, are often afflicted withdysphagia. Symptoms vary from child to childdepending on degree of oral, pharyngeal andesophageal involvement. Some difficulties mayinclude reduced lip closure, the presence of a tonguethrust or tonic bite, reduced movement andcoordination of the tongue, and severe oral-motordifficulties resulting in reduced tongue baseretraction and/or reduced laryngeal elevation(Logemann, 1998). These difficulties can result insignificantly increased mealtime duration, difficultyachieving adequate nutritional intake and increasedrisk for aspiration pneumonia. Children with severedysphagia due to neurodevelopmental disability canbypass the swallowing process and obtain theirnutrition through tubefeeding. G-tube is onetubefeeding option that has become widely used forthis purpose (Razeghi, 2002). Gastrostomy feeding isassociated with increased weight and decreasedfamily stresses at mealtimes. Unfortunately, thisprocedure is also associated with seriouscomplications and can lead to decreased quality oflife (no oral food intake), making it confusing forfamilies and professionals who will make thedecision of whether a child will have a G-tube placedor continue to be fed orally. To further complicatethe issue, there is controversy as to whethergastrostomy prevents aspiration in children withsevere disabilities. It is also suggested thatgastrostomy can worsen the feeding outcomes, suchas increased GER, or even lead to increased mortalityfor children who have the tube placed.

Objectives

To determine the benefits and risks for G-tubefeeding compared to oral feeding for children withneurodevelopmental disabilities. To emphasize theneed and make recommendations for well-conductedresearch on this topic.

Methods


Medline were searched using the following searchstrategy:

((G-tube) OR (gastrostomy)) AND(children) AND ((neurodevelopmentaldisabilities) OR (cerebral palsy) OR(neurologic impairment) OR (mentalretardation)) AND ((aspiration) OR(pneumonia) OR (gastroesophageal reflux)OR (GER)).


Selection CriteriaSelected for inclusion were relevant studies

based on the search strategy above. Participants:children with neurodevelopmental disabilities.Intervention: use of G-tube feeding for nutrition.Outcome: outcome measures included aspiration oraspiration pneumonia, GER, and death.

65

SAFETY OF GASTRONOMY IN FEEDING CHILDREN WITH NEURODEVELOPMENTAL DISABILITIES

Results

Does gastrostomy prevent aspiration pneumonia inneurologically disabled patients?

Although it is generally agreed upon thatgastrostomy produces some health benefits such asimproved hydration and weight gain, the literatureindicates that gastrostomy does not prevent aspirationpneumonia in individuals with neurodevelopmentaldisabilities.

Bui et al. found that postoperative aspirationpneumonia occurred in 18.6% of patients withgastrostomy alone and in 8% of patients who hadgastrostomy and fundoplication. Furthermore, aftergastrostomy, the incidence of aspiration pneumoniaimproved in only 45% of subjects with preoperativeGER.

Hassett et al reviewed the frequency of aspirationpre and post gastrostomy. Overall, at one year aftergastrostomy, the frequency of aspiration had notsignificantly improved. Additionally, it was foundthat a number of patients who had not experiencedaspiration pneumonia prior to tube placement,demonstrated aspiration pneumonia at one year post-gastrostomy. Prior to G-tube placement 29 of 87patients experienced aspiration; after gastrostomy, itwas noted in 35 of 87 patients.

Does gastrostomy produce or exacerbate GER inchildren with neurodevelopmental disabilities?

It is not entirely clear from the results of theliterature, whether gastrostomy placement can cause,maintain or worsen GER in children with severeneurological disability. Four of the five articlesreviewed, concluded that gastrostomy can, atminimum, cause GER to persist, and at maximum,cause GER to develop in children with no history ofGER (Berezin et al, 1986; Heine et al, 1995; Mollittet al, 1985; Samuel et al, 2002).

Mollitt et al. reported, that 25% of patients withan initial negative reflux evaluation experienced GERafter gastrostomy alone. Additionally, 10% ofpatients with a history of GER, experienced recurrentreflux after having gastrostomy and fundoplication.Of the five children studied by Berezin et al., nonehad notable GER prior to G-tube placement. All ofthe children (5/5) were found to have GER aftergastrostomy tube placement and continued toexperience GER after one year of continuousgastrostomy tubefeeding. Heine et al. found thatthere was a significant increase in the clinicalseverity of GER after gastrostomy placement (p <.005). Samuel et al found that no GER pre-PEG ispredictive of a favourable outcome with respect toGER; GER pre-gastrostomy resulted in persistence orworsening of GER and overall, gastrostomy does not

exacerbate the prevalence of GER (all 3 conclusionsat P < .05).

In contrast, Razeghi and colleagues conducted aprospective study investigating the notion thatgastrostomy may influence the development of GERin children. The data in this study suggests that, ingeneral, gastrostomy does not provoke GER (p <.02).

Can tubefeeding contribute to the mortality ofchildren with severe neurodevelopmentaldisabilities?

To test the suggested notion of an associationbetween tubefeeding and mortality, Strauss et al useda retrospective analysis of children with severedisabilities. When no study variables were controlledfor, there was a significant difference in mortalityrates between children who were tubefed comparedto those who were not with a higher mortality rate forthose who were tubefed (p <.01). When controlswere used, there was no significant difference inmortality rate between tubefed, and not, for childrenwith very severe disabilities (p < .01). But, forchildren with less severe disabilities, there was anapproximated doubled mortality rate for children whowere tubefed compared to those who were fed orally.It was proposed that all the children were aspiratingmore frequently with “overly vigorous nutritionalmaintenance and subsequent aspiration after tubeplacement” and that only those with very severedisabilities had also undergone tracheotomy, andtherefore, had ventilation and suctioning, preventingmortality.

Critical Discussion

The sampling type, subject selection, researchdesign and data collection of these seven studiesdiffer considerably from each other. Each of thestudies has weaknesses that may call validity,reliability and the ability to generalize into question.

SampleOf the seven papers reviewed, all used the same

sampling type: purposive sampling. This type ofsample was used due to the specific phenomenon ofinterest (children with neurodevelopmentaldisabilities who are also g-tube fed). While randomsampling is the preferred method, it is clearlyimpossible to randomly assign disability and theethics of randomly assigning subjects to thetreatments G-tube or no G-tube placement arequestionable. The lack of a random sample limitedthe ability to use parametric statistical tests for theseresearchers. It is also difficult to rule out possible

66


confounding variables, such as severity ofimpairment.

SubjectsThere was significant variability of known

subject demographics when comparing these sevenstudies. The following subject demographics wereincluded: sex (4/7 articles); diagnosis or type ofdisability (5/7); g-tube placement procedure (3/7); IQ(1/7); weight (1/7); and severity of disability (2/7).Two of the articles gave very little information abouttheir subjects. This is problematic because thepopulation that the results apply to is unclear.Additionally, these demographics, as well as othervariables, for example, feeding position and method,must be kept constant if the outcomes are to beattributed to the intervention.

DesignAll of the studies examined here are examples of

quasi-experiments as none used random assignmentand most did not use a control group. Morespecifically, six of the seven studies are one-grouppre-test post-tests. This type of quasi-experiment isweakened by the fact that there is no control group.The other study (Strauss et al) is an example of anon-random post-test only design. While this studyhas a ‘control group’ (no g-tube), the groups were notrandomly assigned and the subjects receivinggastrostomy were likely the more severely afflictedgroup.

Data CollectionThe outcome measure ‘presence of aspiration’

was measured by two of the studies. One study (Buiet al) relied solely on medical charts and mentionednothing else and the other (Hasset et al) confirmedaspiration by “the characteristic roentgenologicappearance of a new pulmonary infiltrate,leukocytosis, fever and response to therapy.”

Five articles used ‘presence of GER’ as anoutcome measure with a range of definitions andmethods of confirmation. Three of the seven studiesused clinical measures such as gastric contentsobserved in the mouth, two studies used qualitativemeasures (a parent questionnaire) (Samuel et al;Heine et al), and all five used different combinationsof quantitative measures. Quantitative measureincluded: 24-hour pH-monitoring; gastro-intestinalendoscopy; esophageal biopsy; and bariumesophagram.

Only two of the studies described the personadministering tests. Because experimenter bias is apotential threat to internal validity, the other articlesleave the reader questioning the experimenters’credentials and the agreement between experimenters

if there were more than one. No mention of blindtesting was found in any of the articles.

Conclusions

The present research findings do not provideevidence as to whether gastrostomy is a safe feedingalternative for children with neurodevelopmentaldisabilities. The decision to place a gastrostomy tube(or not) can be confusing for professionals andparents because of the conflicting views andrecommendations of researchers on this topic. Wecan, however, use some of the information providedin the literature to make some clinicalrecommendations for the present. What is clear is theurgent need for a thorough, prospective study,considering many important variables, to come to anycertain conclusions regarding this issue.

Recommendations

Although the existing research does notprovide evidence for or against gastrostomy forchildren with disabilities, it does identify the need fora properly controlled experiment. The issue isethically controversial, yet ideally, a prospective,randomized, controlled-trial experiment isrecommended. This experiment is warranted becauseit is not clear as to whether gastrostomy is abeneficial or potentially harmful treatment for thispopulation as previous research has supported both ofthese possibilities. Therefore, GER and aspirationshould be compared pre and post gastrostomy tubeplacement but also to a randomly assigned, orally fedcontrol group. Another possible comparison wouldbe gastrostomy tube versus jejunum placed tube. Thesample would also need to be more representative ofthe population of children with neurodevelopmentaldisabilities and contain a range of children in respectto age, gender, disability, geographical location, typeof living situation, etc. And we would, of course,want to consider these as variables in the study.Other variables that need to be controlled for, thathave rarely been considered in past studies (probablybecause they were retrospective) are: severity ofdisability (cognitive and physical needs); nutritionaland growth status of the patient; type of measurementused to measure GER and aspiration; type of feedingtube and its surgery procedure; use of antirefluxprocedure; feeding method, rate and position;position after feeding; and whether the procedure wasprophylactic or necessary. It is also recommendedthat future studies use objective, clinical andqualitative measures for aspiration, GER, death,quality of life, and parental stresses.

67


References

Berezin, S., Schwarz S., Halata M., Newman, L.(1986). Gastroesophageal reflux secondary togastrostomy tube placement. American Journalof Diseases of Children, 140 (7), 699-701.

Bui, H., Dang, C., Chaney, R., Vergara, L. (1989).Does gastrostomy and fundoplication preventaspiration pneumonia in mentally retardedpersons? American Journal on MentalRetardation, 94 (1), 16-9.

Hassett, J., Sunby, C., Flint, L. (1988). Noelimination of aspiration pneumonia inneurologically disabled patients with feedgastrostomy. Surgery, Gynecology & Obstetrics,167 (5), 383-8.

Heine, R., Reddihough, D., Catto-Smith, A. (1995).Gastro-oesophageal reflux and feeding problemsafter gastrostomy in children with severeneurological impairment. Journal ofDevelopmental & Behavioral Pediatrics, 37 (4),320-9.

Logemann, J. (1998). Evaluation and treatment ofswallowing disorders. Pro-Ed Inc.: Austin,Texas.

Mollitt, D., Golladay, E., Seibert, J. (1985).Symptomatic gastroesophageal reflux followinggastrostomy in neurologically impaired patients.Pediatrics, 75 (6), 1124-6.

Razeghi, S., Lang, T., Behrens, R. (2002). Influenceof percutaneous endoscopic gastrostomy ongastroesophageal reflux: a prospective study in68 children. Journal of PaediatricGastroenterology & Nutrition, 35 (1), 27-30.

Samuel, M., Holmes, K. (2002). Quantitative andqualitative analysis of gastroesophageal refluxafter percutaneous endoscopic gastrostomy.Journal of Paediatric Surgery, 37 (2), 256-61.

Strauss, D., Kastner, T., Ashwal, S., White, J.(1997). Tubefeeding and mortality in childrenwith severe disabilities and mental retardation.Pediatrics 99 (3), 358-62.

Sullivan, P. (1998). Is tube-feeding in disabledchildren associated with excess mortality?Journal of Paediatric Gastroenterology &Nutrition, 27 (2), 240-41.

68

Copyright © 2005, Isaacs, S.

The significance of age at cochlear implantation

Isaacs, S.M.Cl.Sc. (Aud) Candidate


This critical review examines the effects of age at cochlear implantation on subsequent speech andlanguage development. Overall, although there are methodological flaws in the current research,there is a general consensus that early implantation, particularly during the critical language-learning period, up to age 5, has far-reaching effects on a child’s linguistic development. However,the actual degree of effect as well as an ideal age have yet to be determined.

Introduction

Over the past two decades, over 25,000people have received a cochlear implant(Rubinstein, 2002). These figures will continueto soar due to continuous advances in knowledgeand technology. As more people are receivingthese devices, researchers, clinicians, and parentsalike are questioning the significance of age atimplantation. Until recently, children were noteligible for an implant until at least 2 years ofage due to surgical concerns. The only exceptionwas when a child had been deafened bymeningitis since ossification followingmeningitis may interfere with electrode insertion(Anderson et al., 2004). However, due tohypotheses about a critical language-learningperiod, the U.S. Food and Drug Administration(FDA) have lowered the age of eligibility from 2years of age in 1990 to 1.5 years in 1998 to 1year in 2000 (Geers, 2004). In fact, somecochlear implant groups support earlyimplantation so strongly that they have beenimplanting infants under a year of age (Snik etal., 1997). Researchers have consistently been finding anegative correlation between age at implantationand auditory-verbal abilities, thereby supportingthe notion that early implantation is beneficial tospeech and language development. It should benoted, however, that there is some questionabout the reliability of the current body ofresearch in that most studies are limited in theirdata due to incomplete statistical evaluations,non-homogeneity of variance, and a lack ofconsistency in the methodologies employed.Thus, further research is warranted to determinethe precise effects of early implantation oncommunication skills, as well as an ideal age forreceiving a cochlear implant.

Objectives

The primary objective of this research paperis to determine whether receiving a cochlearimplant at an earlier age significantly impacts achild’s speech and language development. Asecondary objective is to determine the actualeffects of early implantation and whether there isan ideal age. Clinicians require such pertinentinformation so that they may guide parents inmaking informed decisions for their children toensure adequate speech and languagedevelopment.

Methods

Search Strategy Computerized databases, including PubMed,PsycINFO, and Cochrane Library were searchedusing the following strategy:

((Effects) OR (significance) OR(importance) OR (impact)) AND ((age)OR (early)) AND ((cochlear implants)OR (cochlear implantation)) AND(language) AND ((speech) OR (verbal))AND (auditory) AND (development)

Twelve articles were reviewed, all of whichwere published between 1997 and 2004.

Research Design: SubjectsAlthough there is a general lack of

consistency in the methodology, there are somesimilarities in criteria with regards to subjectselection. These include the following:

• Etiology of deafness• Prelingually deafened• Lack of concomitant medical problemsHowever, there are a number of

confounding variables, which should have beenaccommodated for through appropriate andthorough statistical testing, such as Analysis ofVariance (ANOVA), Analysis of Covariance

69

THE SIGNIFICANCE OF AGE AT COCHLEAR IMPLANTATION

(ANCOVA), and Factor Analysis. Some ofthese confounding variables include:

• Age at onset of deafness• Duration (and consistency) of cochlear

implant use• Educational stream special education

or mainstream• Mode of communication before and

af te r implan ta t ion OralCommunication (OC) or TotalCommunication (TC)

• Amount and nature of speech andlanguage intervention

• Concomitant psychological problems,including a low Intelligence Quotient(I.Q.)

• Family issues, such as emotionalsupport and socioeconomic status

• Timing & nature of initial intervention,e.g. was the child (properly) fitted withhearing aids?

• Hearing aid use whether the childwas wearing a hearing aid in the otherear during testing

Research Design: TestingActual testing materials used to assess the

children’s speech and language abilities overtime varied across studies; however, there weresome similarities in the nature of testing, such as:

• Quasi-experimental designs Theseare far more appropriate thanRandomized Controlled Trials (RCT)since it would be unethical to deny animplant to control subjects in a studydue to the irreversible negative impact itcould have on their subsequent speechand language development.

• Regular testing schedules Subjectswere tested pre-, peri-, and post-implantation at 3 or 6 month intervals totrack their development over time.

Ideal Research DesignSome recommendations for future research

are as follows:• Quasi-experimental designs• Longitudinal studies• Thorough statistical testing, especially

to account for all the possibleconfounding variables previouslydiscussed

Results

Results should be interpreted with cautiondue to a lack of methodological consistency andminimal use of statistical testing. Nevertheless,there was a general consensus in the literaturethat early implantation has far-reaching effectsfor a child’s overall linguistic development.This, in turn, may impact on social, emotional,and academic development. Specific advantagesinclude:

• Central Auditory System Electricalstimulation provided by a cochlearimplant minimizes the amount ofauditory deprivation to the peripheralauditory nervous system (Hassanzadehet al., 2002)

• Language delay minimized Althoughthere will inevitably be a languagedelay, earlier implantation may reducethe extent of this delay (Miyamoto etal., 2003)

• Improved reading skills Readinglevels may exceed those generallyexpected of deaf students (i.e. grade 4level) (Rubinstein, 2002).

• Superior voice control (Rubinstein,2002).

• Improved audi tory a t ten t ion(Rubinstein, 2002).

• Interaction more effective parentalinteraction (Rubinstein, 2002).

Conclusions

Although the obvious solution appears to beto implant a deaf child as early as possible, thereare a number of ongoing concerns surroundingthe issue. To begin, there are always risksinvolved in surgical procedures, particularlywhen an infant or child is involved (Anderson etal., 2004). Another issue relates to the reliabilityof hearing tests to accurately diagnose the degreeof hearing loss. A related concern involvesaccurate programming of the implant, as well asthe ability to predict the benefit the child is likelyto receive from the device (Anderson et al.,2004). It may be noted that the latter twoproblems may be minimized with improvedbehavioural and physiological technologies.Lastly, the family must not be overlooked sinceit is not just an ‘ear’ that is being treated. It isnatural for families to require a period to acceptthe diagnosis and explore their options beforedeciding what is best for their child (Geers,2004).

70

THE SIGNIFICANCE OF AGE AT COCHLEAR IMPLANTATION

Overall, the general consensus in theliterature is that early implantation, particularlyduring the critical language-learning period (upto and including age 5), significantly impacts achild’s speech and language development, asearly implantation facilitates the development of‘core listening skills’ (Geers et al., 2003). Theseskills are expected to aid in the development ofspeech and language by enabling the child tomake use of the critical period (Anderson et al.,2004). Moreover, adequate languagedevelopment will likely have a positive impacton the child’s social, emotional, and academicdevelopment. In developing such skills, thesechildren are presumed to have superioropportunities in life, beginning with access tomainstream education.

References

Anderson, I. et al. (2003). Cochlear implantation in children under the age of two – what do the outcomes show us? International Journal of Pediatric Otorhinolaryngology, 68(4), 425-431.Baumgartner, W.D. et al. (2001). The role of age in paediatric cochlear implantation. International Journal of Paediatric Otorhinolaryngology, 62. 223-228.Geers, A.E. (2004). Speech, language, and reading skills after early cochlear implantation. Archives of Otolaryngology and Head and Neck Surgery, 130, 634-638.Geers et al. (2003). Language skills of children with early cochlear implantation. Ear and Hearing, 24(1), 46S-58S.Gordon, K. et al. (2003). Activity- Dependent Developmental Plasticity of the auditory brain stem in children who use cochlear implants. Ear and Hearing, 26(4), 484-500.Govaerts, P.J. et al. (2002). Outcome of cochlear implantation at different ages from 0 to 6 years. Otology and Neurotology, 23, 885-890.Hassanzadeh, S. et al. (2002). The effects of age of auditory speech perception development in cochlear- implanted prelingually deaf children. Otoloarngology-Head and Neck Surgery, 126(5), 524-527.

Lane, H. et al. (1996). A Journey into the Deaf World. U.S.A.: Dawn Sign Press.Miyamoto, R.T. et al. (1999). Communication skills in pediatric cochlear implant recipients. Acta Otololaryngology (Stockholm), 119, 219-224.Rubinstein, J.T. (2002). Paediatric cochlear implantation: prosthetic hearing and language development. The Lancet, 360(9331), 483-485.Snik, A.F.M. et al. (1997). The relation between age at the time of cochlear implantation and long-term speech perception abilities in congenitally deaf subjects. International Journal of Pediatric Otorhinolaryngology, 41, 121-131.Svirsky, M.A. et al. (2004). Development of language and speech perception in congenitally, profoundly deaf children as a function of age at cochlear implantation. International Journal of Pediatric Otorhinolaryngology, 41 121-131.Zwolan, T.A. et al. (2004). Pediatric cochlear implant patient performance as a function of age at implantation. Otology and Neurotology, 25(2), 112- 120.

71

Copyright © 2005, Korzeniecki, T.A.

The accuracy and reliability of blue dye tests for predicting aspiration

Korzeniecki, T.A.M.Cl.Sc. (SLP) Candidate


This critical review examines the usefulness of the blue dye test as a screening tool for aspiration.Overall, blue dye tests seem to be more accurate when their results are positive rather thannegative. More research is needed in this area to make any definitive conclusions.

Introduction

Tracheostomy tubes are normally used forpatients with upper airway obstructions or respiratoryproblems (Logemann, 1998). A tracheostomy tubeplaces a person at risk for aspiration because it maycause reduced saliva and secretion management,disruption of airway pressures, “…reduced laryngealelevation, reduced pharyngeal sensation, reducedcough response, and disuse atrophy of laryngealmusculature” (Brady, Hildner, & Hutchins, 1999, p.146). An inflated cuff is designed to preventaspiration, but it is generally not left fully inflated forlong periods due to tracheal irritation. Even with afully inflated cuff, “…a patient may stillaspirate…due to severe dysphagia or a tracheostomysite placed too high” (Brady et al., 1999, p. 146).

Sophisticated procedures, such as the modifiedbarium swallow (MBS) study, the fiberopticendoscopic examination of swallow safety (FEES),and the video nasal endoscopic examination of theswallow (VEES), are useful in identifying aspiration.However, they are often expensive, time consumingto perform, difficult to access, and may exposepatients to radiation. Due to these potentialproblems, a less sophisticated test is needed.

The Evan’s Blue Dye Test (EBDT) and theModified Evan’s Blue Dye Test (MEBDT) arescreening tools for aspiration for patients who havetracheostomy tubes. The EBDT helps determine ifpatients are aspirating on their own saliva, whereasthe MEBDT screens for aspiration of food andliquids. These blue dye tests “…can be conducted atthe patient’s bedside and in a timely fashion, they arerelatively inexpensive, with as few as one teammember and only suctioning equipment needed, andthey do not expose the patient to any radiation”(O’Neil-Pirozzi, Lisiecki, Jack Momose, Connors, &Milliner, 2003, p. 32). Although blue dye tests havenumerous advantages, their “…accuracy has beenquestioned since the 1980s” (O’Neil-Pirozzi et al.,2003, p. 32).

Objectives

The primary objective of this paper is tocritically evaluate the existing literature regarding theaccuracy and reliability of blue dye tests forpredicting aspiration. The secondary objective is topropose evidence-based practice recommendationsabout whether or not blue dye tests should continueto be conducted.

Methods

Search StrategyThe computerized database PubMed was

searched using the following search strategy:(aspiration) AND (tracheostomy)AND (blue dye) OR (colored dye)

The five selected articles, between 1999 and2003, all examined the usefulness of blue dye testsfor predicting aspiration.

SubjectsAll of the subjects, attained through consecutive

convenience sampling, had tracheostomy tubes andwere referred for a swallowing assessment.

The number of subjects ranged from 15-37.Each subject participated in the research study once,except in the O’Neil-Pirozzi et al. (2003) study.They allowed subjects to participate up to threedifferent times, giving a total of fifty procedures,because each procedure was considered independentof the other forty-nine.

Approximately 70% of the total subjects weremale. The age range between the studies was wide(13-87 years), and the diagnoses of the patients werevariable within the studies.

DesignThe studies used multiple single-subject designs.

There were two independent variables in each study:the blue dye test (BDT) and the sophisticatedprocedure. The dependent variable was aspiration.For the blue dye tests, any blue dye in the trachealsecretions indicated aspiration. For the sophisticated

72

THE ACCURACY AND RELIABILITY OF BLUE DYE TESTS FOR PREDICTING ASPIRATION

procedures, each study indicated what constituted asaspiration with the MBS, FEES, or VEES.Procedures

Two studies performed the MBS simultaneouslywith the BDT (O’Neil-Pirozzi et al., 2003; Brady etal., 1999). Peruzzi, Logemann, Currie, & Moen(2001) administered a short, preliminary MBS studysimultaneously with the blue dye test, and thenperformed a complete MBS immediately afterwards.One study conducted the blue dye test simultaneouslywith the VEES (Donzelli, Brady, Wesling, & Craney,2001), and another administered the FEES within 24hours of the last administration of the blue-dyedbolus (Belafsky, Blumenfeld, LePage, & Nahrstedt,2003).

The studies that performed the sophisticatedprocedure simultaneously with the BDT providedstronger evidence because a patient’s aspirationstatus can change over a short time period. Forexample, a patient may not aspirate on the first test,but may “…aspirate later due to fatigue, poorfollowing of directions, inappropriate bolusconsistencies, or unknown causes” (Leder, 1996, p.80).

Extraneous VariablesThe following variables may have influenced the

results in some of the studies: the cuff status or theremoval of the tracheostomy tube, the frequency ofsuctioning the tracheostomy tube, and bolusconsistency and size.

Results

Descriptive analyses were primarily used, andtwo studies included non-parametric tests as well.

High False-Negative and Absent False-Positive RatesAccording to Brady et al. (1999) and Donzelli et

al. (2001), the blue dye tests had a 50% false-negative error rate for detecting aspiration. When theblue dye tests did detect aspiration in these studies,they detected greater than trace amounts, but nottrace aspiration.

Peruzzi et al. (2001) reported that the positivepredictive value of the BDT was 100% and thenegative predictive value was 47% (+8%). The MBSdetected a significantly greater frequency ofaspiration than the BDT (p<0.05).

High False-Negative and Low False-Positive RatesO’Neil-Pirozzi et al. (2003) examined the overall

aspiration agreement and the consistency-specificaspiration agreement between the MBS and BDT. Inthe overall aspiration agreement, the BDT’s false-negative and false-positive rates were 38.1% and

20.7%, respectively. In the consistency-specificaspiration agreement, the BDT’s false-negative andfalse-positive rates were 71.4% and 20.7%,respectively.

Low False-Negative and High False-Positive RatesBelafsky et al. (2003) reported that the BDT had

a false-negative rate of 18%. The BDT had anoverall sensitivity of 82% and specificity of 38%.The sensitivity increased for patients receivingmechanical ventilation but the specificity remainedlow regardless if the patient was receivingmechanical ventilation or not.

Impact of Specific VariablesO’Neil-Pirozzi et al. (2003) analyzed specific

variables to determine their effect on the aspirationresults. Statistically significant results (p<0.05) werefound only with tracheostomy tube conditions: therewas higher MBS-BDT agreement with a deflatedcuff.

Conclusions

There is no consensus among the currentliterature as to whether blue dye tests can accuratelyand reliably predict aspiration. Four of the fivestudies demonstrated that the blue dye tests had anabsent or relatively low false-positive rate and a highfalse-negative rate. This suggests that if blue dye ispresent in the tracheal suctioning, then the person islikely aspirating. However, if blue dye is absent inthe tracheal suctioning, the person may still beaspirating. According to two of these studies, bluedye tests are more likely to show false-negativeresults for trace aspiration versus greater than traceaspiration. Based on this information, a possiblerecommendation for clinicians is to perform asophisticated procedure whenever the blue dye testsindicate negative results in order to reveal if theperson is truly aspirating. Otherwise, unsaferecommendations, such as deflating the cuff andputting the person on a monitored diet, may be madeif the results suggest that a person is not aspiratingwhen he/she really is.

More research is needed in this area, and futurestudies should incorporate useful features from theprevious studies and make changes to improve theresearch design. Useful features include performingthe sophisticated procedure simultaneously with theblue dye test, videotaping the sophisticated test, andhaving multiple people independently rate theaspiration severity on the blue dye test and thesophisticated test. Possible changes that can be madeinclude using larger sample sizes, random samplingfrom multiple locations and time periods, controlling

73

THE ACCURACY AND RELIABILITY OF BLUE DYE TESTS FOR PREDICTING ASPIRATION

extraneous variables, using the kappa correlationcoefficient for inter-rater reliability, and calculatingstatistical significance. In addition, future studiesshould investigate the impact of different factors (e.g.bolus characteristics, tracheostomy tube conditions)on the blue dye tests’ accuracy and reliability, as wellas the tests’ reliability in detecting trace aspirationversus greater than trace aspiration.

Due to the advantages that blue dye tests haveover sophisticated procedures, clinicians shouldcontinue to conduct the bedside evaluation with ablue dye test rather than without one. The blue dyetests may provide valuable information when theresults are positive. Clinicians still have to becautious, however, when making recommendationsbased on blue dye tests’ results, particularly when theresults are negative. It is imperative that cliniciansuse their experience and clinical skills during thebedside evaluation to make important decisions andto determine if the patient should be referred for asophisticated test of aspiration.

References

Belafsky, P.C., Blumenfeld, L., LePage, A., & Nahrstedt, K. (2003). The accuracy of the modified Evan’s blue dye test in predicting aspiration. The Laryngoscope, 113(11), 1969- 1972.Brady, S.L., Hildner, C.D., & Hutchins, B.F. (1999). Simultaneous videoflouroscopic swallow study and modified Evans blue dye procedure: An evaluation of blue dye visualization in cases known of aspiration. Dysphagia, 14(3), 146-149.Donzelli, J., Brady, S., Wesling, M., & Craney, M. (2001). Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. The Larnygoscope, 111(10), 1746-1750.Leder, S.B. (1996). Comment on Thompson-Henry and Braddock: The modified Evan’s blue dye procedure fails to detect aspiration in the tracheostomized patient: five case reports. Dysphagia, 11(1), 80-81.Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Texas: PRO- ED Inc.O’Neil-Pirozzi, T.M., Lisiecki, D.J., Jack Momose, K., Connors, J.J., & Milliner, M.P. (2003). Simultaneous modified barium swallow and blue dye tests: A determination of the accuracy of blue dye test aspiration findings. Dysphagia, 18 (1), 32-38.Peruzzi, W.T., Logemann, J.A., Currie, D., & Moen, S.G. (2001). Assessment of aspiration in patients

with tracheostomies: Comparison of the bedside colored dye assessment with videofluoroscopic examination. Respiratory Care, 46(3), 243-247.Thompson-Henry, S., & Braddock, B. (1995). The modified Evan’s blue dye procedure fails to detect aspiration in the tracheostomized patient: Five case reports. Dysphagia, 10 (3), 172-174.Tippett, D.C. & Siebens, A.A. (1996). Reconsidering the value of the modified Evan’s blue dye test: A comment on Thompson-Henry and Braddock (1995). Dysphagia, 11(1), 78-79.

74

Copyright © 2005, McGraw, C.

Impact of long-term pediatric tracheostomyon speech and language development

McGraw, C.M.Cl.Sc. (SLP) Candidate


This critical review examines the relationship between early long-term tracheostomy and speechand language development. The research studies reviewed include quasi-experimental designs anda single-subject longitudinal design. Overall, the research suggests that children with a history oflong-term tracheostomy are at risk for speech and language problems. Further research needs tobe conducted, however, in order to systematically document the speech and languagecharacteristics and difficulties demonstrated by this population.

Introduction

Advances in the medical management ofrespiratory compromise in preterm and medicallyfragile infants have led to increased numbers ofchildren undergoing early tracheostomy.Tracheostomy involves the surgical placement of anopening, or stoma, and the insertion of a tube, orcannula, into the trachea at the base of the neck.With the cannula in place, the breath stream isdiverted to and from the lungs through the stoma,bypassing the upper respiratory tract. As a result,there is a significant alteration in the physiologicalfunctioning of the upper airway. Perhaps the mostsignificant alteration in terms of normal growth anddevelopment is the restriction in voice use. Althoughnot all tracheostomized infants are aphonic (unable toproduce sound), most are severely restricted in theirability to vocalize (Kertoy, 2002; Simon, Fowler &Handler, 1983).

It has been postulated that early vocal play andbabbling provide the necessary oral-motor practiceand auditory feedback to develop correspondencesbetween speech sounds and specific oral-motormovements (Oller, Wieman, Doyle & Ross, 1975;Vihman, Ferguson & Elbert, 1987). Due to thevoicing restrictions imposed by the cannula,tracheostomized infants are limited in theiropportunities to engage in such early speech practiceand auditory monitoring. Given both the documentedincrease in the number of children undergoing earlytracheostomy (i.e. prior to 13 months of age) and theincrease in the average period of cannulation (i.e.typically longer than 12 months), there appears to bea growing number of children suffering lengthy voicerestrictions during a crucial developmental period(Singer, Kercsmar, Legris, Orlowski, Hill, &Doershuck, 1989). Consequently, the need toinvestigate the impact of long-term tracheostomy onthe speech and language development of these infants

has become an issue of significant clinicalimportance.

Objectives

The primary objective of this paper is tocritically evaluate the existing literature regarding theimpact of long-term pediatric tracheostomy onspeech and language development. The secondaryobjective is to propose an evidence-based practicerecommendation about the type of approach thatshould be adopted when working with these ‘at-risk’children.

Methods


Cochrane Library, PsycINFO and PubMed weresearched using the following search strategy:

((tracheostomy) OR (trach*)) AND((pediatric) OR (paediatric) OR (infant*)OR (child*) AND (communication) OR(speech) OR (language)).



review paper examined the impact of earlytracheostomy on speech and/or languagedevelopment. No limits were set on thedemographics of research participants or outcomemeasures.

Data CollectionThe literature search yielded five articles, four of

which employed quasi-experimental designs (4), andone which utilized a single-subject longitudinaldesign (1).

75

IMPACT OF LONG-TERM PEDIATRIC TRACHEOSTOMY ON SPEECH AND LANGUAGE DEVELOPMENT

Results

Impact of Long-term Pediatric Tracheostomy onLanguage

Kaslon and Stein (1985) addressed the effect ofchronic tracheostomy on the acquisition of speechand language skills in ten children who weretracheostomized prior to 12 months of age and priorto “meaningful vocal communication” (mean age attracheostomy: 4.6 months). At the time of testing,the children ranged in age from 16 and 41 months.These children were found to demonstrate delays inboth their expressive and receptive language skills asevidenced by their scores on the Sequenced Inventoryof Communication Development (SICD). Theauthors reported an average of 4.8 months delay inreceptive language skills and 9 months delay inexpressive language skills. Moreover, they reporteddeficits in oral/vocal speech and voice productionbased on clinical perceptual ratings. They alsosuggested that the majority of children assessed aslanguage delayed responded favourably to speechand language intervention.

Simon, Fowler and Handler (1983) alsoexamined the impact of long-term tracheostomy onlanguage development. Their study consisted of 23children who were tracheostomized for periodslasting 6 months to 6.9 years. These children werecategorized as ‘prelinguistic’ or ‘linguistic’depending on whether or not they had opportunitiesvocalize consistently prior to the placement of thetube as well as their level of language development atthe time of decannulation. Speech and languageassessment included both standardized and subjectivemeasures (see Appendix II for a list of the testsutilized). The results of testing indicated that childrenwho were decannulated during the prelinguistic stage,“prior to acquisition of true expressive language,”had language skills commensurate with their overallintellectual functioning. By contrast, 7 out of 9children who were decannulated later during thelinguistic stage (i.e. when word production emerges)evidenced expressive language delays; 3 had severedelays of several years or more while 4 showeddelays of approximately 4 to 10 months. Given thesefindings, the authors proposed that the age atdecannulation and length of tracheostomy withrespect to early periods of language development arecrucial to the observed outcomes in this population ofchildren. They also reported that direct speech andlanguage intervention during the linguistic stage iscrucial for maximizing the communication skills ofthese children.

Impact of Long-term Pediatric Tracheostomy onSpeech

Simon, Fowler and Handler (1983) alsoinvestigated the impact of long-term tracheostomy onthe development of speech. Commensurate withtheir findings in the area of language, they noted thatchildren who were decannulated during theprelinguistic period demonstrated near normalphonological skills post-decannulation. By contrast,children who were decannulated during the linguisticstage showed enduring phonological difficulties post-decannulation. Again, these results seem to suggestthat the timing and duration of tracheostomy arecritical to the observed developmental sequelae inthese children. That is, cannulation extending intothe linguistic stage may be particularly detrimental tospeech and language development.

Hill and Singer (1990) also documentedwidespread articulation difficulties in 61% of theirsample. Their sample consisted of 31 children whowere tracheostomized between the ages of 2;1 and8;6 years (mean age at cannulation: 4.2 months; meanduration of cannulation: 31 months). Given thatarticulation impairments were noted up to 8.5 yearsof age, these results suggest that tracheostomizedchildren may experience long-lasting difficulties.

In their longitudinal study of a single subject,Locke and Pearson (1990) examined the sounddevelopment patterns of a tracheostomized childfrom 16 to 21 months of age (age at tracheostomy: 5months; age at decannulation: 21 months). Theyfound that during this period and immediately post-decannulation, the child’s rate of canonical syllableproduction (i.e. consonant-vowel syllables) and thesize of her consonant inventory were significantlyreduced from normal. Indeed, both were reportedlyapproximate to those of an infant less than 6 monthsof age. However, during follow-up testing at 4 yearsand 4 months, they reported that she had attainednear-normal speech production. These findingssuggest that early, long-term tracheostomy may beassociated with severely restricted speech productionabilities at the time of decannulation, but that theseskills may ‘bounce back’ in the months/yearsfollowing tracheostomy.

Finally, in their 1999 study, Kertoy, Guest, Quartand Lieh-Lai examined the speech production andphonological skills of 6 tracheostomized childrenwho ranged in age from 2;8 to 6;8 years (mean age atcannulation: 3 months; average length of cannulation:30 months). The speech production patterns of thesechildren were documented at two different points intime using detailed phonetic, phonological andacoustic analyses (approximately 3 months separatedexperimental analyses). These authors found thatwhile each child demonstrated a unique pattern of

76


speech production difficulties, all the childrenexhibited excessive use of one or more phonologicalprocesses. The most frequently observed processeswere Stridency Deletion (e.g. omitting /s/ in“house”); Liquid Deviation (e.g. substituting /w/ for/r/ in “rabbit”) and Cluster Reduction (e.g. omitting/l/ in “please”). These types of processes involvephonetic classes and sound distinctions that areacquired later in the sound sequence. This mayindicate that these children are simply delayed intheir sound acquisition skills (i.e. do not show anatypical pattern of sound development), and thatthese skills are gradually acquired following removalof the tracheal tube.

Overall, the research indicates that early, long-term tracheostomy may be detrimental to the speechand language development of children. However, thereviewed studies have some methodologicalweaknesses that make interpretation of their resultssomewhat problematic. To begin, all of the reviewedstudies relied on non-probability sampling proceduresfor subject recruitment. Subjects were chosen on thebasis of availability (i.e., convenience sampling).Although these non-probability methods areappropriate given the research question at hand,because subjects were not selected at random, itcannot be assumed that the obtained samples providea valid representation of population characteristics oftracheostomized infants as a whole.

The sample sizes also tended to be small.Although Hill and Singer (1990) and Simon et al.,(1983) included 31 and 23 subjects in their samplerespectively, the remaining researchers only had 10or fewer subjects. Smaller samples are less likely toprovide an accurate representation of populationcharacteristics. This, in turn, leads to a reduction inpower and well as a reduction in the generalizabilityof the results (i.e. the findings may not pertain to allchildren with a history of tracheostomy, but only asubset with characteristics equivalent to thoserepresented in the sample).

Subject data were also often poorly described.For instance, two of the studies did not clearlyspecify the age at which the children weretracheotomized (Hill & Singer, 1990; Simon et al.,1983). Rather, they indicated large age ranges duringwhich their subjects underwent tracheotomy (0-13months and 0-24 months, respectively). Withoutmore specific information on the age of cannulation,it is difficult to predict the amount of pre-speechpractice these children may have experienced prior totracheostomy. Indeed, those children who werecannulated at 24 months in Simon et al.’s (1983)study likely progressed through the babbling stageand into the linguistic stage prior to tracheostomy.This would undoubtedly distort the results. In

addition, Hill and Singer, (1990), Simon et al., (1983)and Kaslon and Stein (1983), failed to clearly specifythe age at which the children were decannulated. Infact, in Kaslon and Stein’s study, it is not clear if allsubjects are decannulated at the time of testing.Without more specific information on the ages ofdecannulation, it is difficult to predict the extent ofthe imposed voicing restrictions experienced by thesechildren and by extension, to interpret the resultsbased on these data.

Several researchers also grouped their subjectdata, despite the fact that the subjects had beencannulated for disparate lengths of time (Hill &Singer, 1990; Simon et al., 1983). That is, theytreated children with considerably different historiesand opportunities for speech/language use as ahomogeneous group. Again, this wide within-groupvariability makes interpretation of the influence ofvoicing restrictions on speech and languagedevelopment difficult.

Moreover, there are a number of coexisting riskfactors associated with pediatric tracheostomy thatmay have influenced the observed pattern of speechand language in these children. These include:prematurity, low birth weight, periods of anoxia,developmental delays, long-term or recurrent hospitalstays, concurrent illnesses, and Otitis media. Thesefactors could not be easily controlled for given thepopulation of infants under investigation. Kaslon andStein (1985) failed to control for any such factors.Other researchers made more rigorous attempts, butwere unable to eliminate them completely. Forinstance, Hill and Singer (1990) excluded infantsfrom their study who evidenced primary neurologicalimpairments, severe physical disabilities, or mentalretardation. However, 50% of the infants includedwere born prematurely, 25% weighed less than 1500g at birth and 29% evidenced mild neurologicalproblems. This lack of stringent control is alsoapparent in Kertoy et al.’s (1999) and Simon et al.’s(1983) studies. It is not clear, then, whether it istracheostomy itself, or the impact of tracheostomy inconcert with other variables that is responsible for theobserved speech and language difficulties in thesechildren.

While Locke and Pearson’s single case study(1990) provided insight into the changes in onechild’s speech development preceding and followingdecannulation, a single data set may not berepresentative of the population as a whole. Thefindings need to be replicated before any firmconclusions can be drawn regarding the observedpattern of results.

Finally, the majority of studies used generalstandardized indexes to assess the speech andlanguage abilities of these children. While these tests

77


are reliable and valid, and therefore, appropriate,information about specific patterns of errors anddifficulties would provide an invaluable addition tothese more broad observations.

Implications for Practitioners working with Childrenwith a History of Long-term Tracheostomy

Given the methodological issues present in thereviewed studies, the interpretations that can be mademust be somewhat tempered. However, sometentative conclusions can be drawn. Taken together,the reviewed studies indicate a general pattern ofdelay. While it is unclear whether the speech andlanguage skills of these children ‘rebound’ followingdecannulation, there is sufficient evidence to suggestthat these children are, at the very least, at risk forspeech and language difficulties. This may beparticularly true for those children who arecannulated into the linguistic period.

This information is crucial for guidingpractitioners in their work with this population andtheir families. Outcome data will allow practitionersto inform families about the potential developmentalimplications of tracheostomy and help them developrealistic expectations for their child’s speech andlanguage progress.

Given that these children represent an ‘at-risk’population, it is recommended that practitionersadopt a proactive approach in working with them andtheir families. Ongoing monitoring and possiblereferral for services are required if their speech andlanguage skills are to be optimized.

Further research documenting specific patternsof speech and language demonstrated is warranted. Itwould allow practitioners to be alert to specificdifficulties experienced by these children and guideearly identification and intervention efforts.

Conclusions

Research has demonstrated that early long-termtracheostomy may have a negative impact on speechand language development. Overall, it seems to leadto a general delay in speech and language skills,rather than an atypical presentation ofcommunication abilities. Further research isnecessary to determine whether these observeddelays are long-lasting impairments, or whether, withspeech and language practice, the children acquirethese skills gradually.

Future research should focus on detailing thespecific speech and language characteristics of thispopulation. Moreover, systematic studies evaluatingthe efficacy of specific intervention procedureswould be helpful in guiding practitioners in theirtreatment of these children. Such outcome data would

help to close “the current knowledge-practice gap”faced by practitioners and help them to support andencourage the emerging speech and language of theseyoung children (Kertoy, 2002, p. xii).

References

Arvedson, J. C., & Brodsky, L. (1992). Pediatrictracheostomy referrals to speech-languagepathology in a children’s hospital. InternationalJournal of Pediatric Otorhinolaryngology, 23,237-243.

Hill, B. P., & Singer, L. T. (1990). Speech andlanguage development after infant tracheostomy.Journal of Speech and Hearing Research, 55,15-20.

Hodson, B. W. (1986). The assessment ofphonological processes – revised. Danville, IL:Interstate.

Kaslon, K. W., & Stein, R. E. (1985). Chronicpediatric tracheostomy: Assessment andimplications for habilitation of voice, speech andlanguage in young children. InternationalJournal of Pediatric Otorhinolaryngology, 9,165-171.

Kertoy, M. K. (2002). Children withTracheostomies: Resource Guide. New York:Singular Publishing.

Kertoy, M. K., Guest, C. M., Quart, E., & Lieh-Lai,M. (1999). Speech and phonologicalcharacteristics of individual children with ahistory of tracheostomy. Journal of Speech,Language, and Hearing Research, 42(3), 621-635.

Locke, J. F., & Pearson, D. M. (1990). Linguisticsignificance of babbling: Evidence from atracheostomized infant. Journal of ChildLanguage, 17, 1-6.

Oller, D. K., Wieman, L, Doyle, W., & Ross, C.(1975). Infant babbling and speech. Journal ofChild Language, 3, 1-11.

Simon, B. M., Fowler, S. M., & Handler, S. D.(1983). Communication development in youngchildren with long-term tracheostomies.International Journal of PediatricOtorhinolaryngology, 6, 37-60.

Singer, L. T., Kercsmar, C., Legris, G., Orlowski, J.P., Hill, B. J., & Doershuck, C. (1989).Developmental sequelae of long-termtracheostomy. Developmental Medicine andChild Neurology, 31, 224-230.

Vihman, M., Ferguson, C. A., & Elbert, M. (1987).Phonological development from babbling tospeech: Common tendencies and individualdifferences. Applied Psycholinguistics, 7, 3-40.

78

Copyright © 2005, Meade, K.

Efficacy of treatment approaches in developmental apraxia of speech

Meade, K.M.Cl.Sc. (SLP) Candidate


This critical review examines the efficacy of treatment approaches in Developmental Apraxiaof Speech (DAS). Overall, research in this area is not extensive and fails to provide a strongevidence base for efficacious treatments in DAS. Recommendations are discussed, includingthe need for more research.

Introduction

For the purposes of this paper, DAS is defined asan inability to carry out movement of the speecharticulator(s) in the absence of impairedneuromuscular function (Sussman, Marquardt, &Doyle, 2000). DAS is also known by many othernames including developmental verbal apraxia,apraxia of speech in children, and childhood apraxiaof speech.

Children diagnosed with DAS characteristicallyhave difficulty with volitional movements and as aresult they do not respond well to traditional speechand language treatments (Powell, 1996). It isimportant for speech-language pathologists to gain afull understanding of the available treatment optionsin order to best meet the unique needs of childrenwith DAS.

Objectives

As a clinical professional there is a growing needto make informed clinical decisions based on theavailable research and evidence base. The potentialof having to make decisions based on questionableand sometimes weak evidence is alarming andreduces clinicians’ confidence in those decisions.The integrity of clinical and professional practice isdependent on the evidence base. The current authorreviewed research regarding the efficacy oftreatments in developmental apraxia of speech(DAS).

Search Criteria

Computerized databases including PsychInfo andM e d l i n e were used to search apraxia ORdispraxia/dyspraxia OR developmental apraxia ORapraxia of speech OR AOS OR developmentalapraxia of speech OR DAS OR paediatric apraxia ORpaediatric motor speech OR verbal apraxia ORapraxia of speech in children OR childhood apraxiaof speech AND treatment. Articles selected had the

following criteria: (1) they examined DAS; (2) theystudied treatment for DAS; (3) they madeconclusions about treatment for DAS.

Articles Reviewed

Ballard (2001)Ballard (2001) conducted a critical review of

studies that examined treatment efficacy in DAS andmade clinical recommendations for treatment.However, it is unclear how many studies wereconsidered for review, how many were actuallyreviewed, and how the selected articles were chosen.One cannot be sure that those articles selected forreview were representative of the best and mostcurrent literature within the field. Additionally, therewas no description of how the studies were reviewed,no outcome measures, and no procedure wasoutlined. Without this information the paperpresented as a positional paper rather than a criticalreview. Opinion cannot be evidence itself because itlacks empirical data.

Although not a critical review, Ballard presentedclear statements about how practice in DAS treatmentneeds to be modified to include more recent advancesin research, and she included some valid clinicalimplications surrounding task complexity and patientcharacteristics.

In light of Ballard’s weak methodology andopinion-based results, the study cannot be consideredrigorous enough to contribute to the evidence base ofresearch regarding treatment efficacy in DAS.

Powell (1996)Powell (1996) examined stimulability

considerations in the phonological treatment of achild with DAS. As Powell’s research design was acase study results would be difficult to generalize toother children; this one child cannot be representativeof the population with DAS. Powell used multipleoutcome measures from four domains: neurological,adaptive and intellectual, language, and speechproduction. Overall, the study’s outcome measures

79

EFFICACY OF TREATMENT APPROACHES IN DEVELOPMENTAL APRAXIA OF SPEECH

had mediocre psychometrics and it is unclear why somany were used. Lengthy testing can easily fatigue aparticipant, potentially altering test scores becausethe child may not have been performing at fullpotential. Over testing can also result in the subjectlearning behaviours and responses expected of him(i.e. ‘teaching to the test’). This may produce skewedscores that are not representative of the participant’sabilities, potentially altering the results of treatmenteffects.

There were procedural and experimental controlconcerns in this study because multiple examiners,facilities, and testing dates were used. Not onlywould the procedures be difficult to replicate, thelack of control leaves readers uncertain if thereported changes in phonetic inventory were due toexperimental treatment, other treatment, ormaturation.

Powell stated the increase found in phoneticinventory could not be due to maturation because ofthe participant’s history of slow phonologicaldevelopment. This suggests the author believesphonological development is linear, when in fact it isoften dynamic; slow phonological development atone point in time is not predictive of continual slowphonological development.

In summary, it is difficult to have confidence inthis study in light of the issues surroundinggeneralizability, replicability, unjustified over testing,and confusing research design. Without confidencein this research study we cannot definitively say thatit contributes to the evidence base of treatmentefficacy in DAS.

Strand and Debertine (2000)Strand & Debertine (2000) used an across

behaviours multiple baseline single subject design todetermine if the integral stimulation approachintroduced by Rosenbek, Lemme, Ahern, Harris, &Wertz (1973) could be efficacious in the treatment ofDAS. The study did not employ outcome measuresbut claimed that prior to treatment their 5-year-oldparticipant had normal receptive language, goodcognition, excellent pragmatic skills, and was 10%“comprehensible” indicating what they considered apure DAS case. However, without outcomemeasures no psychometric data is available andfurthermore, there is no basis for their pure DASclaim or their treatment results based on this claim.In addition, the article admitted their measure ofcomprehensibility was “rough”; a roughly measuredcriterion is subject to the tester’s perception ratherthan empirical evidence. It would be difficult to notechange as a result of the treatment when using only a“rough” measure and therefore we cannot necessarilyattribute their results to the treatment itself.

Overall, Strand and Debertine’s lack of outcomemeasures reduces any confidence that could beplaced in their results. In light of their methodology,this study’s contribution to the evidence base isdiminished as a result of one’s reduced confidence.

The critical review of results revealed the authorsnoted differences in speech production and theyattributed changes to treatment effects. However,there is some concern as to the amount of confidencethe reader can have in their results due to thefollowing. First, to analyze their data Strand &Debertine developed a binary scoring system thatappeared to be arbitrary in nature. The authorsestablished the criteria for “significant” results; thisindicates experimenter bias as their investment intheir results may have influenced how their data wasscored. Second, they reported values of “about 0.25to about 0.8”; the term “about” leaves the readerunsure of the authors’ own confidence in theirscoring system and results. Third, no conventionalstatistics were reported even though performing anANOVA would have been appropriate. In addition,Strand & Debertine included numerous graphsdepicting their results. These graphs were verydetailed and appeared to contain all of their data butwere extremely hard to interpret. It would have beenmore valuable to use less complex graphs so thereader could clearly understand the results beingdemonstrated.

Without statistical data or clearly presentedgraphs it is very difficult for the reader to haveconfidence in the authors’ statement about treatmenteffects. Therefore, this study does not contribute tothe evidence base of treatment efficacy in DAS.

Sussman, Marquardt, & Doyle (2000)Sussman et al. employed a between-subjects

research design to examine acoustic analysis ofphonemic contrastiveness in DAS. They agematched five normally developing children with fivechildren with DAS. It is not clear why only tenchildren were studied and there was no mention of apower analysis. With so few participants, significantresults are more difficult to achieve and as such, theremay have never been the potential for significance inthis study. Another methodological weakness wastheir use of a speech acoustic outcome measure, locusequation (LE), to quantify acoustic forms of stop +vowel utterances. The authors attempt to describeLEs and what they are used for, but used overlycomplex language and detail. This lack of clarity inmethodology decreases its rigour leaving the readerunsure if the study can contribute to the evidencebase. If the reader is not familiar with the function ofLE, he/she cannot interpret any results provided, or

80


understand the greater purpose of Sussman et al.’sstudy.

Examination of the authors’ results revealedreports of exact slope values, results in graph format,and the inclusion of waveforms. If, as above, thereader is lacking sufficient background knowledge inspeech acoustics, it is difficult for the reader tointerpret results without having to consult additionalresources. This is not practical for clinicians as it isvery time consuming; it is likely that the articlewould be discarded before embarking on furtherinvestigation.

Furthering the reader’s uncertainty of the study’sstatistical analyses, it appears Sussman et al.abandoned their research design part way throughtheir investigation. They had intended to compare anormally developing group to a DAS group that wereage-matched. Instead, they compared the differencesbetween the groups against a single adult subject’sresults. While Sussman et al. found that the DAS didnot approximate the formant values of the adultsubject, the normally developing group did.However, the authors only discussed the results ofthree of the five normally developing groupmembers. This failure to include data on the othertwo participants leaves the reader to believe that thedata may not have been favourable. This lowers ourconfidence in results because they excluded datawithout explanation, thereby jeopardizing internalvalidity. Therefore, Sussman et al.’s failure toprovide rigorous results decreases the reader’sconfidence that the study contributes to the evidencebase of treatment efficacy in DAS.

Recommendations

Review of selected literature regarding efficacyof treatment in DAS has revealed weaknesses, flaws,and inconsistencies. Overall, the articles reviewedreported little to no statistical analysis, and weak andoften vague methodology. Therefore, there is a needfor more rigorous research of treatment efficacy inDAS. In absence of a rigorous evidence base, it isdifficult to know where treatment should go fromhere; the needs of the individuals with DAS on ourcaseloads must be managed. It is recommended thata Delphi survey of clinicians practicing in the area ofDAS be conducted to establish the current state oftreatment.

However, more pressing than the issue oftreatment is that of diagnosis as discovered whendetermining search criteria for this critical review.Current diagnosis criteria presents as inconsistent;two of the four articles reviewed acknowledgedvague diagnosis criteria. This acknowledgementdemonstrates the authors’ awareness that their

findings needed to be interpreted with cautionbecause they used formal diagnosis of DAS as basisfor participant inclusion. If formal diagnosis of thedisorder itself is questionable, then it is difficult todetermine if the authors were even able to conductresearch examining its treatment. Conversely, theremaining studies did not address diagnosticconcerns. This is problematic because one has toquestion if the authors accounted for problems informal diagnosis within their own research.

D e v e l o p m e n t o f m o r e r e l i a b l einclusion/exclusion criteria through research will helpus identify those characteristics that identify DAS. Itis essential to clearly identify DAS and its salientcharacteristics before discussions regarding treatmentoptions and their efficacy can take place. Essentially,treatment cannot be efficacious if diagnosis remainsquestionable.

In conclusion, it is the recommendation of thisauthor to look to similar disorder areas rich inevidence to establish acceptable treatment for theseindividuals with DAS. For example, in motorlearning theory, repetitive practice of small chunks ofinformation and is emphasized. Similarly, acquiredapraxia of speech (AOS) encourages repetitivelearning that establishes small gains over longerperiods of time. Frattali, C., Bayles, K., Beeson, P.,Kennedy, M.R.T., Wambough, J., and Yorkston,K.M. (2003) as part of a committee commissioned byThe Academy of Neurologic CommunicationDisorders and Sciences (ANCDS) reviewed theliterature surrounding AOS in attempt to developguidelines based on research evidence. They madeseveral recommendations, which included theidentification of three categories of clinicalcharacteristics important to ensure accurate andconsistent diagnosis of AOS. Category onecharacteristics are those necessary for a correctdiagnosis (e.g. slow speech rate, speech sounddistortions); category two characteristics arenondiscriminative in terms of differential diagnosis(e.g. articulatory groping); and category three arethose inappropriate for diagnosis (e.g. anticipatorysound errors). Overall, Frattali et al. (2003)concluded “evidence supporting various approachesto the treatment of AOS appeared to be meagre andrather weak” (p. xiii). Suitably, a similar committeerecently initiated a comparable study with DAS butresults were not available at the time this review wasconducted.

Research in apraxia, like the above article, isessential to determine efficacious treatmentapproaches for DAS. If Frattali et al. had been ableto provide a good evidence base of treatment efficacyfor AOS we could have extrapolatedrecommendations for DAS. However, it appears as

81


though the AOS evidence base shows similarweaknesses to that of DAS. This further supportsthis author’s recommendations that at present,treatments of DAS are not efficacious and moreresearch in treatment and predominantly diagnosis,needs to be conducted.

References

Ballard, Kirrie J. (2001). Response generalization inapraxia of speech treatments: Taking anotherlook. Journal of Communication Disorders, 34,pp3-20.

Frattali, C., Bayles, K., Beeson, P., Kennedy, M.R.T.,Wambough, J., Yorkston, K.M. (2003).Development of Evidence-Based PracticeGuidelines: Committee Update. Journal ofMedical Speech-Language Pathology, 11 (3). ppix-xviii.

Powell, T. (1996). Stimulability considerations in thephonological treatment of a child with apersistent disorder of speech-sound production.Journal of Communication Disorders, 29,pp315-333.

Strand, E., & Debertine, P. (2000). The efficacy ofintegral stimulation intervention withdevelopmental apraxia of speech. Journal ofMedical Speech-Language Pathology, 8 (4).pp295-300.

Sussman, H., Marquardt, T., & Doyle, J. (2000). Anacoustic analysis of phonemic integrity andcontrastiveness in developmental apraxia ofspeech. Journal of Medical Speech-LanguagePathology, 8 (4). pp301-313.

82

Copyright © 2005, Miller, N.J.A.

The efficacy of different treatment approachesfor Parkinsonian dysarthria

Miller, N.J.A.M.Cl.Sc. (SLP) Candidate


This critical review examines the effectiveness of the three main treatment approaches forParkinsonian dysarthria. Study designs include: review article, single-subject pretest-posttestdesign, multiple-baseline design, single-subject multiple-baseline design, pretest-posttest withcontrol group design, and group pretest-posttest design. Overall, research supports the use of allthree approaches for treating individuals with Parkinsonian dysarthria. However, due to use ofdifferent variables, designs, and statistical analyzes in the various studies, the most efficaciousapproach has not been determined.

Introduction

Parkinson’s disease (PD) is a progressive,degenerative disease that results from a reduction inthe release of dopamine within the striatum of thebasal ganglia. Symptoms such as tremor, rigidity,akinesia, and postural abnormalities lead to thedifferential diagnosis of PD. In addition to thesesymptoms, PD can affect the speech mechanism, aproblem classified as Parkinsonian dysarthria orhypokinetic dysarthria. Hypokinetic dysarthria hasspeech characteristics including reduced stress,monopitch, monoloudness, short rushes, variable rate,imprecise consonants, breathy voice, and harsh voice(Schultz & Grant, 2000).

A range of treatment options are available for theremediation of speech symptoms related toParkinsonian dysarthria. These treatments range fromtraditional speech therapy approaches to lesstraditional surgical treatments. Three types oftreatment methods are addressed herein. These are:intensive speech therapy (including the use oftherapeutic devices, and treating speech prosody),pharmacological treatment, and surgical treatment.Research has not yet identified the best interventionfor improving voice and speech symptoms in thesedysarthric speakers.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theefficacy of different treatment approaches forParkinsonian dysarthria. The secondary objective isto propose evidence-based practice recommendationsabout the effectiveness of treatment for thispopulation.

Methods

Search StrategyComputerized databases, including PubMed,

Medline and CINAHL, were searched using thefollowing search strategy:

((Parkinson’s disease) AND (dysarthria))AND ((Treatment) OR (Therapy)).



review paper were required to investigate the impactof any type of treatment for Parkinsonian dysarthria,on speech and voice symptoms.

Data CollectionThe results of this constrained literature search

produced the following types of articles: reviewarticle (1), single-subject pretest-posttest design (1),multiple-baseline design (1), single-subject multiple-baseline design (1), pretest-posttest with controlgroup design (1), and group pretest-posttest design(1).

Results

Impact of Speech Therapy on ParkinsonianDysarthria

Wearable Biofeedback Device:Rubow & Swift (1985) conducted a single-

subject pretest-posttest study evaluating the impact ofbiofeedback information on a subject’s speechintensity. Results were broken down into three maincategories: perceptual ratings, acoustic analysis, andmicrocomputer vocal intensity.

In terms of perceptual ratings, a more rapidimprovement for reading was found, compared to

83

THE EFFICACY OF DIFFERENT TREATMENT APPROACHES FOR PARKINSONIAN DYSARTHRIA

conversation. The acoustic analysis foundimprovements, revealed by visible periodicoscillations and scattered aperiodic energy. Themicrocomputer vocal intensity calculated the averagetime between low-intensity alarms from themicrocomputer during spontaneous speech, bothinside and outside the clinic. It was found that duringthe second phase of treatment, the alarm intervalswere greater than those during the first phase(indicating that there was a longer time betweenalarms in the second phase).

Delayed Auditory Feedback:Hanson & Metter (1983) utilized a multiple-

baseline design (n=2) to examine the effect ofdelayed auditory feedback on Parkinsonian speech.For each patient, a statistical comparison betweennormal auditory feedback (NAF) and delayedauditory feedback (DAF) measures were made usinga t-test for correlated observations (paired). Data wasanalyzed for both reading and conversation on fivemain dimensions: speaking rate, intensity, meanfundamental frequency (Fo), intelligibility, andmaximum phonation time.

Patient A demonstrated statistically significantimprovements in three of the five dimensions. Forspeaking rate, DAF was shown to produce asignificant change (t = 9.49) in overall slowness ofreading. For in tens i t y in both reading andconversation, there was a significant increase in vocalintensity with the use of DAF (t = 7.59 and t = 9.06,respectively). For intelligibility, statisticallysignificant improvements were seen for both readingand conversational measures (t = 12.99 and t = 12.12,respectively).

Patient B demonstrated statistically significantimprovements in four of the five dimensions. Forspeaking rate, a slowness of rate was documented inboth reading and conversational situations (t = 4.67,and t = 3.29, respectively). For intensity, an increasewas documented during the reading condition (t =4.75). For mean Fo, an increase in fundamentalfrequency was found to be statistically significant (t =10.50) in the reading condition. For intelligibility, astatistically significant increase was documented withDAF in the conversation condition (t = 4.99).

Intensive Speech Therapy:LeDorze, Dionne, Ryalls, Julien, & Ouellet

(1992) conducted a single-subject multiple-baselinedesign to examine the effect of intensive speechtherapy on speech prosody in dysarthric speech.Results were divided into three main sections:acquisition of treated behavior, maintenance effectsof therapy, and generalization.

The acquisition of treated behavior revealed thatthe subject was found to: increase frequency rangebetween declarative and interrogative sentences,increase mean Fo in declarative sentences, anddecrease speech rate. The maintenance effects oftherapy revealed that the patient was able to maintainall treated behaviors 10 weeks later. Thegeneralization measures were determined through theuse of (a) the dysarthria profile, (b) social validitymeasures, and (c) intonation measures. Thedysarthria profile revealed noted improvements inrespiration; but did not note changes in phonation,facial musculature, diadochokinesis, or articulation.Social validity was determined by having judgescomplete sentence transcription of pre-treatment andpost-treatment sentence pairs; then classify sentencesas declarative or interrogative. For intonation, theaccurate identification of pre- and post-treatmentsentence pairs was found to be statistically significant(t = 6.413).

Impact of Pharmacological Treatment onParkinsonian Dysarthria

Goberman, Coelho, and Robb (2002)implemented a pretest-posttest with control groupdesign (n=18) to examine the effects of the ON andOFF states of drug treatment on Parkinsonianpatients. Three main hypotheses were tested, andresults were classified into two categories: (a)UPDRS motor score results and (b) phonation results.

The UPDRS scores showed that PD patientswere most impaired in the OFF state (low dopaminelevels), shown by high UPDRS scores; and leastimpaired in the ON1 state (high dopamine levels),shown by lower UPDRS scores. The phonationresults were analyzed through: descriptive analysis,effect size analysis, and statistical significancetesting.

Hypothesis 1 predicted that there would be adifference between the control subjects and the PDsubjects (in their OFF state) on all measures. It wasfound that there was moderate-high support based onvowel, reading, monologue Fo’s, and intensity range.Pairwise analysis showed a significant differencebetween the PD subjects and controls for: Fo inreading and monologue tasks, and SDFo in prolongedvowels and intensity range.

Hypothesis 2 stated that the PD subjects wouldimprove on all measures of phonation in the ON1compared to OFF state. Descriptive analysisrevealed low support for this hypothesis in allmeasures of phonation. Few subjects demonstrateddecreased mean Fo in the ON1 compared to OFFstate. Most subjects demonstrated comparable valuesin the ON1 compared to OFF state. Effect sizeanalysis revealed low support in all measures as well.

84


Repeated measures and ANOVA results indicatednon-significant effects for Fo in vowels, Fo inmonologue, Fo in reading, and intensity range(p>0.05).

Hypothesis 3 stated that there would be nodifference between the ON1 and ON2 state phonationmeasures. Descriptive analysis found variablesupport for this hypothesis, based on the mean Fodata from the ON1 and ON2 states, but wascalculated to be moderate-high support overall. Inaddition, effect size analysis also found moderate-high support for all measures. The ANOVAcomparisons revealed no significant differences(p>0.05), leading to little overall support for thishypothesis.

Impact of Surgical Treatment on ParkinsonianDysarthria

Gentil, Pinto, Pollak, & Benabid (2003) utilizeda pretest-posttest design (n=16) examining the effectsof bilateral subthalamic nucleus (STN) stimulation onspeech production in dysarthric speakers. Subjectswere studied in two conditions: during bilateralstimulation, and 30 minutes after stoppingstimulation. Results were divided into three maincategories: UPDRS scores, force assessment, andacoustical analysis.

For the UPDRS scores, motor disabilityimproved with bilateral stimulation 30-95%. Speechimpairment improved on average from a score of 2before stimulation, to a score of 1 after stimulation(where 0=normal, and 4=unintelligible).

The force assessment measures analyzed data ofthe upper lip, lower lip, and tongue. Statistical t-testsshowed that the unstimulated condition yieldedsignificantly smaller maximal forces then thestimulated condition (upper lip – t=5.34, p<0.01;lower lip – t=4.94, p<0.01; tongue – t=3.92, p<0.01).For all three articulatory organs, the mean reactiontime in the stimulated condition was significantlyshorter (upper lip, t=6.88; lower lip, t=6.60; tongue,t=4.88, all at p<0.01) than in the unstimulatedcondition. The force rise time for all stimulatedpatients was also significantly shorter (p<0.01) thanwhen unstimulated, regardless of the target interval.For the hold phase, during the stimulated condition,patients were closer to the target (whatever its level),and therefore were significantly more precise(p<0.01) than in the unstimulated condition with eacharticulatory organ. As indicated by greater standarddeviation (SD) in statistical testing, the hold phaseduring the unstimulated condition was not as steadyas that of the stimulated condition.

Acoustical analysis revealed that whenstimulated, patients showed the following: longermaximum phonation time of /a/ and /i/; shorter

duration of the repeated word /pataka/ at a fast rate;shorter pause duration; and larger relative intensityduring a 30 second phrase repetition. Fundamentalfrequency (Fo) measures revealed that whenstimulated, patients showed larger variabilitybetween the beginning and end of each phaseproduction, as well as greater stability of Fo duringsustained vowels. Analysis of intensity in sustainedvowels revealed stability of intensity in bothunstimulated and stimulated conditions.

Discussion

The research evidence from these studiessupports the implementation of each intervention,with some important cautionary notes. With theexception of Goberman et al. (2002), each of thesestudies employed a quasi-experimental design, wherethere was no random assignment, and no controlgroup. Another issue was that each of the studiesreviewed used a small convenience sample. Resultsbased on few participants may be problematic froman external validity standpoint, and so one might notbe able to generalize to other PD patients.Furthermore, the variability of the disorder, and theseverity of the disease in the subjects studied, mayimpact on the external validity of any researchproject.

Further research needs to be done to examine theefficacy of each intervention. The effectiveness ofeach intervention should be compared using similarvariables, designs, and statistical analyses. Whenconsidering which of the three treatments is mostefficacious, one must consider some of thelimitations of treatment, such as motor fluctuationsduring drug treatment (i.e., inconsistent ON and OFFperiods), and the inherent heterogeneity of theParkinsonian population (i.e., patients differ in theirage, age of disease, duration of disease, severity ofsymptoms, and responsiveness to treatment).

Recommendations

In conclusion, it is not possible (or advisable) torecommend one treatment over another, solely on thebasis of the evidence reviewed herein. As previouslymentioned, this literature review has shown that eachtreatment method targets different variables ofspeech. Furthermore, it is evident that speechtherapy has been shown to improve speechcharacteristics such as prosody, vocal intensity, rate,and intelligibility. Pharmacological treatment hasresulted in improvements for speech and voice insome PD patients. Regardless of its impact onspeech, drug treatment is required to control themotor symptoms of PD. Surgical treatment has

85


demonstrated improvements in increased forcemeasurements of the articulators, increases inintensity and fundamental frequency variability.Moreover, if a patient presents with specific speechand voice symptoms, clinicians can use theinformation outlined in this review to determine themethod of treatment that is best suited to theirpatients.

Future research should employ a pretest-posttestexperimental design, in the examination of a largegroup of Parkinsonian subjects. Patients should berandomly assigned to a treatment condition in whichthere would be individuals representing all stages ofthe disease (early, middle, and late). Finally, allresearch in this domain needs to consider theheterogeneity of the Parkinsonian population, andstrive to control demographic variables when creatingcomparison groups.

References

Gentil, M, Pinto, S., Pollak, P., & Benabid, A.L.(2003). Effect of bilateral stimulation of thesubthalamic nucleus on Parkinsonian dysarthria.Brain and Language, 85, 190-196.

Goberman, A., Coelho C., & Robb, M. (2002).Phonatory characteristics of Parkinsonian speechbefore and after morning medication: the ON andOFF states. Journal of CommunicationDisorders, 35, 217-239.

Hanson, W.R. & Metter E.J. (1983). DAF SpeechRate Modification in Parkinson’s Disease: AReport of Two Cases. In: Berry, W.R. (ed),Clinical Dysarthria. College Hill Press: SanDiego. 231-251.

LeDorze G., Dionne L., Ryalls, J., Julien, M. &Ouellet, L. (1992). The effects of speech andlanguage therapy for a case of dysarthriaassociated with Parkinson’s disease. EuropeanJournal of Disorders of Communication, 27,313-324.

Rubow, R. & Swift, E. (1985). A microcomputer-based wearable biofeedback device to improvetransfer of treatment in Parkinsonian dysarthria.Journal of Speech and Hearing Disorders, 50,178-185.

Schultz, G. & Grant, M. (2000). Effects of speechtherapy and pharmacologic and surgicaltreatments on voice and speech in Parkinson’sdisease: A review of the literature. Journal ofCommunication Disorders, 33, 59-88.

86

Copyright © 2005, Parsa, V.

Acoustic Signal Processing Research at the National Centre for Audiology

Parsa, V.School of Communication Sciences and Disorders andDepartment of Electrical and Computer EngineeringThe University of Western Ontario, London, Ontario

A vast majority of current generation hearing aids, assistive listening devices, and augmentativecommunication devices employ sophisticated digital signal processing (DSP) techniques forspeech and audio processing. However, there is a limited body of work on systematicallyevaluating the relative performance these techniques. Our research attempts to fill this gap byperforming both instrumental and subjective evaluations of DSP technologies, with the goalimproving their overall performance. Specific projects include : (a) evaluation and developmentof digital noise reduction algorithms in hearing aids, (b) evaluation of speech coding technologiesin cellular and voice over internet communications, and (c) evaluation of directional hearing aidsand multi-microphone arrays.

87

Copyright © 2005, Perin, N.

Perceptual awareness and speech therapy treatmentfor patients with Parkinson’s disease

Perin, N.M.Cl.Sc. (SLP) Candidate


This critical review examines the effects of perceptual awareness difficulties among persons withParkinson’s disease. In addition, it examines the effects of various speech therapy treatments onthis population. Study designs include: 4 experimentally designed studies on the speech andlanguage therapy techniques used for Parkinson’s disease patients, and two quasi-experimentalstudies on the perceptual awareness of speech in this population group. Ultimately, this literaturereview proposes to suggest the best approach to treating the speech and language disorders ofpatients with Parkinson’s disease. Overall, There is considerable evidence to support that some PDpatients exhibit impairment in the perceptual awareness of their speech. However, theidentification of one exemplar therapy for persons with Parkinson’s disease, who have sensoryperceptual problems, does not yet exist. Therefore, the findings raise the question as to whetherclinicians should use therapy techniques that require PD patients, noted to have impaired self-perception, to use these skills to have success in therapy.

Introduction

Parkinson disease is a progressive neurologicaldisease caused by dopamine deficiency in thesubstantia nigra (Ramig et. al, 2001). This movementdisorder has primary physical symptoms (tremor,rigidity, akinesia, and postural stability), whichultimately have been seen to affect the musclesinvolved in speech (Ramig, 1998). Researchersbelieve that as many as 50-90% of individuals willdevelop speech and voice disorders in the course oftheir illness (Ramig, Fox and Sapir, 2004). Theseeffects, on both speech and voice production, form agroup of disorders classified as hypokineticdysarthria (Stemple et al., 2000). As has beendescribed, (Darley, Aronson, & Brown, 1975)hypokinetic dysarthria includes a group of relatedspeech disorders that are due to disturbed muscularcontrol over the speech mechanism. The classicdescription of the speech of these patients includesreduced loudness, monotony of pitch, short rushes ofspeech, and imprecise consonants. There are alsonumerous other characteristics that have an affect onthe speech of individuals with PD including: reducedstress, monoloudness, inappropriate silences, rapidrate, harsh voice, breathy voice, and low pitch(Darley, Aronson and Brown, 1975).

Historically there have not been many clinicalresearch studies that address the use of behaviouralspeech therapy for patients with PD. In the past, therewere no indications of a standard therapy approach,which may suggest why speech treatment forParkinson disease patients was not prevalent. Thisproblem may still exist since in 1996 in the UnitedStates, reports suggest that only about 4% of patients

with Parkinson’s disease received treatment for theirspeech (Ramig et al., 1996).

One of the many problems that have beenencountered with speech therapy with PD patients inthat past is that the techniques learned in therapy arenot easily transferable to everyday use. In fact it hasbeen said, “changes that occur in the speechtreatment room disappear on the way to the parkinglot” (Stemple, 2000). Maintaining the improvementsof speech therapy and carrying them over to daily lifesituations is one of the major concerns of clinicians.For example, one of the most common initial speechsymptoms is the perception of reduced loudness.Patients often complain that they are becoming softspoken (hypophonic) and are becoming frustrated byfrequent requests to repeat themselves (Adams,1997). The problem with carryover of therapy may bethat a patient may sound like they have adequateloudness in a quiet clinic room but fail to compensateto noisier situations.

Therefore, three varying behavioural therapytechniques used to treat different speech problems inthe Parkinson disease patients were examined. Aspecific behaviour therapy in speech and languageconducted by Scott and Caird (1983) focused on thespeech prosody of PD patients. The prosodicexercises that were used as a therapy technique (Scott& Caird, 1983) aimed at increasing the patient’sawareness of the abnormal prosodic features inhis/her own speech. The general theoretical ideabehind this technique is one of sensory awarenessand self-awareness driving the improvement inspeech difficulty.

Another behaviour therapy that focuses onincreasing the respiratory effort of PD patients is

88

PERCEPTUAL AWARENESS & SPEECH THERAPY TREATMENT FOR PATIENTS WITH PARKINSON’S DISEASE

termed respiratory effort therapy (RET). Thistreatment technique looks at changing thephysiological mechanism that is disordered ratherthan targeting a perceptual difficulty. The RETtreatment focuses on physiologic changes in muscleactivity (i.e. increased inspiratory and expiratorymuscle activity) to increase subglottal air pressureand respiratory volume. As a result, the perceptualchange in loudness occurs (Ramig et al., 2001).

Lastly, Lee Silverman Voice Treatment orLSVT® is a very intensive and specific speechtherapy program that focuses on the disordered voiceof individuals with Parkinson’s disease (Ramig,1998). The LSVT® program follows five basicconcepts that include: (1) thinking loud; (2) highspeech effort; (3) intensive treatment; (4)recalibrating loudness level; (5) quantifyingimprovements (Steeple et al., 2000). By usingLSVT® speech-language pathologists encouragepatients to produce a loud voice at all times inaddition to using all the effort they can (Ramig,1998). The theoretical idea behind LSVT® includesboth physiological change as well as perceptualawareness in its training.

Comparing the theoretical construct of thesevarious therapy techniques is important because itquestions whether speech-language pathologistsshould be using techniques that rely heavily onperceptual skills. Research suggests that sensorykinesthetia problems may be a factor in the speechand voice disorder observed in individuals with PD(Ho et al., 2000). The same authors (1999) comparedvoice loudness perception in individuals withidiopathic Parkinson’s disease with hypophonicdysarthria with neurologically normal speakers. Theyfound that unlike normal speakers the PD patientsover-estimated the loudness of their speech duringboth reading and conversation (Ho et al., 1999).

Objectives

The objectives of this study are to criticallyevaluate the research literature regarding theperceptual abilities of PD patients and to furtherassess the effectiveness of various speech treatmentswith patients with PD.

Search Strategy

Relevant experimental studies were identified byelectronic searches of MEDLINE, CINAHL,HealthSTAR, PsycINFO, PubMed, and the CochraneLibrary. These were searched using the followingsearch strategy:

((Parkinson’s disease) OR (parkinsonism))AND ((speech-langauge therapy) OR(speech therapy) OR (voice therapy) OR(communication) OR (speech treatment) OR(voice treatment) OR (speech-languagetreatment)).


Results

Perceptual AwarenessTwo of the research studies reviewed deal with

the perceptual skills of patients with PD. One of theresearch studies looks at various conditions in whichpatient’s perceptual awareness can be tested.Researchers look at the patient’s regulation of speechvolume for reading and conversation with (i)background noise (ii.) instantaneous auditoryfeedback and (iii.) an attention cue given by theclinician (Ho et al., 1999). The other study (2000)looks at the patient’s perceptual ratings of volumeimmediately after speaking and after their speech isplayed back to them under three conditions: they aretold to speak quietly, loudly, and normally.

In Ho et al. (1999), the first experiment foundthat controls significantly decreased their volumewith increasing IAF, but PD participantsdemonstrated minimal decrease for both reading andconversational speech. The researchers found a maineffect for group, where PD’s were seen to read andconversed, more softly than controls. Also found amain effect for volume (p=0.0001). The controlgroup gradually decreased reading volume asauditory feedback volume increased and heard theirown voice getting louder. In the second experiment,controls significantly increased their volume withincreasing BGN (p=0.014; partial eta-squared=0.675), but PD participants (p= 0.0001;partial eta-squared=0.243) demonstrated minimalincrease for both reading and conversational speech.In the last experiment, the researchers found that bothgroups increased reading volume from soft to loud tovery similar extents although controls achieved aslightly greater range (p= 0.05).

The general findings in Ho et al. (2000)concluded that control participants were louder thanPD participants overall. Control participantsincreased volume to a greater extent than PDparticipants did for normal and loud instructions(p<0.001, p<0.001). For the measure of immediateperception, they found that PD participantsconsistently overestimated volume relative tocontrols (p<0.01). In addition, in the playbackperception researchers reported that PD participantsconsistently overestimated volume relative to

89


controls (p<0.001). Therefore, although patientsspoke more quietly than control subjects, theyperceived (immediately and on playback) that theirspeech was louder than controls.

Speech TherapyTwo of the research studies involve direct

comparison of the LSVT® speech and languagetherapy technique versus respiratory effort treatment(RET) in patients with idiopathic Parkinson’s disease.One concentrates on the immediate effects (Ramiget. al, 1995) and the other looks at patients after a 2-year period (Ramig, et al., 2001a). Another studycompares treatment of voice disorders in PDindividuals using LSVT® to PD patients who receiveno treatment and to normal age-matched controls(Ramig et al., 2001b). Lastly, a “traditional” therapyapproach, which focuses on studying the effects ofprosodic exercises versus prosodic exercises withvisual feedback, is examined (Scott & Caird, 1983).

Ramig et al. (1995, 2001a), evaluated a numberof outcome variables including these instrumentalmeasures: intensity, maximum duration of sustainedvowel, fundamental frequency and variability, rateand utterance duration, pause duration. In addition,perceptual ratings included self-ratings of loudness,monotonicity, hoarseness, initiating conversation, andintelligibility; family-ratings of l o u d n e s s ,monotonicity, hoarseness, initiating conversation,and intelligibility; and depression and quality of lifescales. Overall, Ramig et al (1995, 2001a) found thatthe Lee Silverman Voice treatment (LSVT®) resultedin significant improvement in mean SPL (volume)and STSD (pitch) for the three speech tasks from pre-treatment to post, and from pre-treatment to 24months. They also concluded that respiratory efforttherapy (RET) showed improvement in SPL andSTSD from pre-to immediately post-treatment duringRainbow passage, however no significant differencesfrom pre-treatment to 24-month follow-up occurredin any of the tasks.

In addition the outcome findings a repeatedANOVA revealed no significant difference betweenthe two groups at baseline for: age, stage of disease,motor portion of UPDRS score, glottal incompetence,and severity of speech disorder. Authors attributedthe unequal n sizes due to “lack of subjectcompliance with pre- and post-treatmentassessments.” The authors also did not analyze theirdata on an intention to treat manner. Patients thatwithdrew from the study were simply withdrawnfrom the data.

Family members’ assessments of the patient’sspeech was only measured at baseline andimmediately after therapy, and they did not say howthey chose the 12 LSVT patients, and the 8 patients

in the RET group for this measure. Intra subjectreliability was tested by including 58% of subjects ina second pre-treatment voice recording, 36 % ofsubjects in a second post-treatment voice recording.The authors do not state why all the patients are notincluded in these measures, and how these patientswere chosen to be re-tested.

The various methodological deficits affect thequality of evidence presented in the Ramig et alpapers. Generally, the small number of patients, theunequal group sizes, and questionable randomizationpose problems. In addition, the possible publicationbias affects the interpretation of results.

In the literature completed by Scott & Caird(1983), the general findings suggest that both groupsstudied (Group A: prosodic exercises (PE) and GroupB: PE with visual cues) showed an improvement(p<0.005, p<0.001). They noted the mostimprovement occurred in the group that receivedprosodic therapy without visual feedback.

The results showed no significant difference inscores for both groups pre-treatment. As for thecomparison between the groups, groups A and Bshowed little difference in their scores from pre-treatment to immediately after treatment. There wasno significant difference within group B fromassessment 3 to 4. At best guess this is probably whygroup B got an extra 2 weeks of therapy andassessment. There was also a significant decrease inthe prosodic abnormality scores (noted improvement)between assessments 3 and 5 (group A) andassessments 4 and 5 (group B). Group A showed agreater change of the mean scores on both of theoutcome measures. In addition group B was stated tohave “maintained benefit” as seen in the decrease ofscores from assessments 2 and 5.

No homogeneity of variance was reported. Theauthors reported that patients included in this studyare probably representative of patients with thespeech disorder typical of PD, in respect of age,duration of disease and current therapy treatmentgroups.

Recommendations

There is considerable evidence shown throughthe rigorous studies on the perceptual awarenessskills in PD patients to say that patients withconsiderable perceptual deficits should be treatedappropriately. However, there isn’t enough evidencein the literature reviewed to say which treatmentreviewed is most effective for these types of patients.

Therefore, this raises the question of whetherclinicians should use therapy techniques that requirePD patients (noted to have perceptual problems) touse these skills to have success on a therapy goal.

90


Ultimately, clinicians should not stop trainingthese skills. In fact, treatments like LSVT® that focuson training these specific awareness skills may be themost successful for maintaining learned skills.Emphasis on self-monitoring is an important part ofthe treatment in all PD patients. It would be useful tolook at additional comparisons between groups ofpatient’s receiving various treatments (LSVT® vs.other standard treatments) to see the long-term effectsof this training. Keeping in mind that methodologicalquality is improved.

The implication of this review on clinicalpractice is that as clinicians we should be aware ofthe perceptual deficit that some of these patientsexhibit. Therefore, clinicians may spend timeassessing and probing this aspect of perceptualawareness of their voices before investing the timeand effort into an intensive treatment program.Modulating current therapy programs to includeperceptual awareness tasks may be another possiblesolution.

Ultimately, speech-language pathologists mayneed to evaluate many different situations todetermine how their speech improvements madeduring therapy can be maintained long term. One ofthe many problems that have been encountered withspeech therapy with PD patients in that past is thatthe techniques learned in therapy are not easilytransferable to everyday use. Look at various settingsfor treatment, to improve on the real life difficultiesthat may be encountered. These concerns ofperceptual awareness deficits may lead researchersand clinicians to look at other approaches totreatment such as instrumental devices (e.g.,visual/auditory feedback devices) to maintaincarryover from speech and language treatment.

The implication for further research anddevelopment of speech treatments for dysarthricpatients with PD is needed. Moreover, furtherresearch should focus on improving methodologysuch that the results of the studies can guide us toanswers regarding the outcome of treatment ofdysarthria in Parkinson’s disease.

References

Darley, F., Aronson, A., & Brown, J. (1975). MotorSpeech Disorders, Philadelphia: Saunders.

Deane, KHO., Whurr, R., Playford, ED., Ben-Shlomo, Y., & Clarke, CE. (2002). Speech and

language therapy for dysarthria in Parkinson’sdisease: a comparison of techniques (CochraneReview), The Cochrane Library, Issue 3.

Ho, A.K., Bradshaw, J.L., and R. Iansek (1999).Speech Volume Regulation in Parkinson’sDisease: effects of implicit cues and explicitinstructions. Neuropsychologia, 37:1453-1460.

Ho, A.K., Bradshaw, J.L., Iansek, R. and R.Alfredson (2000). Volume Perception inParkinsonian Speech. Movement Disorders,15:1125-1131.

Ramig, L.O., Countryman, S., & Thompson, LL.(1995). Comparison of two forms of intensivespeech treatment for Parkinson disease. Journalof Speech and Hearing Research, 38(6): 1232-51.

Ramig, L.O., Countryman, S., O’Brien, C., & Hoehn,M. (1996). Intensive speech treatment forpatients with Parkinson's disease: short-and long-term comparison of two techniques. Neurology,47(6): 1496-504.

Ramig, L.O., & Dromey, C. (1996). Aerodynamicmechanisms underlying treatment relatedchanges in vocal intensity in patients withParkinson Disease. Journal of Speech andHearing Research, 39:798-807.

Ramig, L.O. (1997) How effective is the LeeSilverman voice treatment? American Speech-Language-Hearing Association, 39(1): 34-5.

Ramig, L.O. (1998). Treatment of speech and voiceproblems associated with Parkinson's disease.Topics In Geriatric Rehabilitation, 14 (2): 28-43.

Ramig, L.O, Sapir, S., Countryman, S., Pawlas, AA.,O’Brien, C., Hoehn, M., & Thompson, LL.(2001a). Intensive voice treatment (LSVT) forpatients with Parkinson's disease: a 2-yearfollow-up. Journal of neurology, neurosurgery,and psychiatry, 71: 493-498.

Ramig, L.O., Sapir. S., Fox, C., & Countryman, S.(2001b). Changes in vocal loudness followingintensive voice treatment (LSVT®) inindividuals with Parkinson’s disease: Acomparison with untreated patients and normalage-matched controls. Movement Disorders,16:79-83.

Scott, S. & Caird, F.I. (1983). Speech therapy forParkinson’s disease. Journal of Neurology,Nerosurgery and Psychiatry, 46:140-144.

Stemple, J. (2000). Voice therapy: clinical studies,San Diego: Singular Publishing Group.

91

Copyright © 2005, Philp, S.

Identifying and confirming the presence ofauditory neuropathy/dys-synchrony

Philp, S.M.Cl.Sc. (Aud) Candidate


This critical review examines the tests currently used to identify and confirm auditoryneuropathy/dys-synchrony. Study designs include: critical review and case control. Overall,research supports the use of otoacoustic emission and auditory brainstem response screening testsas means to identify this disorder, and otoacoustic emission, auditory brainstem response, middleear muscle reflex and cochlear microphonic testing for confirmation of auditory neuropathy/dys-synchrony.

Introduction

Auditory neuropathy/dys-sychrony (AN/AD) is acondition whereby the patient presents with auditorycharacteristics consistent with normal outer hair cellfunction, and abnormal neural function at the level ofthe vestibulocochlear (VIIIth) nerve. Moreover,many of these patients exhibit various degrees ofhearing impairment, as well as significant difficultyhearing in noise, well beyond what would have beenpredicted from their pure tone audiogram (Berlin,Hood, Morlet, Rose, & Brashears, 2003). Inaddition, other audiological tests reveal normaltympanograms, absent middle ear muscle reflexes, nomasking level difference, and no efferent suppressionof transient evoked otoacoustic emissions in responseto one or both ears (Berlin et al., 2003; Hood, 1998).

The auditory responses typical of auditoryneuropathy have led some authors to recommendrenaming this condition to auditory dys-synchrony asit may provide a more accurate description of what isoccurring in these patients. For example, otoacousticemission (OAE) testing, which is sensitive to outerhair cell function, is normal in these patients.However, absent auditory brainstem response (ABR)and middle ear muscle reflexes, without a site oflesion, as well as temporal disruption, reveals dys-synchrony of the VIIIth nerve (Hood, 2002).

The actual abnormality present in these patientsis unknown. The disorder could be at the level of theinner hair cells, the synapse between the inner haircells and VIII nerve fibres, the ganglion neurons, thenerve fibres, or any combination of the above (Starr,Picton, Sininger, Hood, & Berlin, 1996). Rance,Beer, Cone-Wesson, Shepherd, Dowell, King,Rickards, & Clark, (1999) state that “a number ofauthors have suggested that AN could be associatedwith a loss of myelin and could be localized to theType 1 afferent auditory nerve fibres” (p.246).

However, normal outer hair cell function, asdemonstrated by the normal OAEs, and abnormal

neural function seen in ABR tests, suggests thepathology may be at the level of the inner hair cellsor their synapse with Type 1 auditory nerve fibres.This suggested site of pathology cannot be ruled outhowever, as there are no tests currently available forthis purpose (Rance et al., 1999; Rapin & Gravel,2003; Starr et al., 1996).

Since AN/AD is characterized primarily ashaving normal outer hair cell function andabnormal/de-synchronous auditory nerve function,tests that are sensitive to both cochlear function andauditory nerve function are a necessity for properidentification of this disorder. To assess outer haircell function, OAE testing is the most sensitive, andABR testing is the most sensitive to auditory nervedysfunction (Berlin et al, 2003, Dolphin, 2004, Hood,1998).

Used independent of one another, OAE and ABRtest results will not provide adequate information todiagnose auditory neuropathy. However, when usedconcurrently, these tests “offer insight into preneuralas well as neural function in the auditory system andthus may form the most sensitive combination”(Hood, 1998, p. 13).

In addition to the OAE and ABR tests, otherclinical tests exist which are sensitive to cochlearfunction and auditory nerve function. These includecochlear microphonics (CM), middle ear musclereflexes (ipsilateral and contralateral) (MEMR),masking level difference (MLD), efferentsuppression of transient evoked otoacousticemissions (TEOAE), and word recognition testingwith an ipsilateral competing noise (Hood, 1998).

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding thecurrent tests being used to identify and confirm thepresence of auditory neuropathy/dys-synchrony. Thesecondary objective is to propose evidence-based

92

IDENTIFYING AND CONFIRMING THE PRESENCE OF AUDITORY NEUROPATHY/DYS-SYNCHRONY

practice recommendation about a best-practiceprotocol for screening and confirming the presence ofthis disorder in patients.

Methods


Cochrane Library, were searched using the followingsearch strategy:

((Auditory neuropathy) OR (Auditory dys-synchrony)) AND (screening) OR(identification) OR (confirmation) OR(diagnosing)).

The search resulted in a collection of articleswritten in English between 1971 and 2004.


review paper were required to investigate auditoryneuropathy/dys-synchrony, the types of tests beingused to screen for the disorder, and the tests beingused to confirm the presence of the disorder. Nolimits were set on the demographics of patients.


following types of articles congruent with theaforementioned selection criteria: critical review (9),and case control (4).

Results

A Review of Test MethodsAlthough the OAE and ABR test combination is

widely accepted as the standard tests required foridentification of AN/AD (Berlin et al., 1998;Dolphin, 2004; Hood, 1998), it is worthwhile toreview the clinical tests that have been used orsuggested for use in identifying and confirmingauditory neuropathy/dys-synchrony in the articlesthat were included in this critical review.

OAE and ABR testing is recommended in eacharticle as a necessary part of the procedure foridentifying and confirming the presence of AN/AD.Some authors (Berlin et al., 2003; Hood, 1998; Katz,2002; Rapin & Gravel, 2003) also recommendadditional tests, such as cochlear microphonics andmiddle ear muscle reflexes in order to properlyconfirm this disorder.

According to the current Infant Hearing Programprotocol and guidelines for audiologic assessment inOntario, cochlear microphonics and the ABR are therecommended tests to use for confirming thepresence of this disorder. However, it also statesthat:

“The appropriate course of action, given aprobable AN, is at the discretion ofthe individual IHP audiologist. An ancillaryprotocol that will address additionaldiagnostic procedures, as well asmanagement issues, is in preparation”(p. 21).

There are many issues to consider regarding themost appropriate tests to use for these patients. Partof the difficulty arises in the diversity seen amongthese patients, particularly in regards to their hearingthresholds, which can range between near normal tosevere to profound (Berlin, Hood, Morlet, Rose, &Brashears, 2003). As well, there is no actual site oflesion.

Screening for Auditory Neuropathy/Dys-synchronyThe implementation of newborn hearing

screening programs has enabled OAE screening of allinfants, and ABR screening on those infants that donot pass the OAE screening, and high risk babies.The combined use of OAE and ABR screening on allhigh risk infants does indeed provide the requiredinformation to identify auditory neuropathy.However, for infants without any risk factors, thecurrent infant hearing program protocol used inhospitals will not identify a child with auditoryneuropathy. This is due to the two-stage screeningprotocol, which does not require an ABR screeningtest if the infant presents with normal OAE’s. Thisprocess will therefore not identify auditoryneuropathy in the infant since, by definition of thedisorder, he or she will have normal OAE test results.

Without a complete screen of the auditorypathway, an infant with auditory neuropathy may goundetected for years, and the child is at risk formisdiagnosis of either mental retardation or centralauditory processing disorder, due to hearing andlanguage difficulties despite normal outer hair cells(Berlin et al, 2002). AN/AD is currently not includedas a disorder targeted for identification throughnewborn hearing screening programs in the currentJoint Committee on Infant Hearing Year 2000Position Statement, although it does recommendaudiologic and medical monitoring of infantsconsidered to be at risk for AN/AD.

Confirming the Presence of AuditoryNeuropathy/Dys-Synchrony

As there are currently no tests available to assessinner hair cell function or their synapses with VIIInerve fibres, the next best option is the OAE andABR tests. In addition to the OAE and ABR tests,there are several other tests available that can provideadditional information about cochlear and neuralfunctioning which can aid the audiologist in

93


diagnosing AN/AD. These include cochlearmicrophonics (CM), middle ear muscle reflexes(ipsilateral and contralateral) (MEMR), maskinglevel difference (MLD), efferent suppression oftransient evoked otoacoustic emissions (TEOAE),and word recognition testing with an ipsilateralcompeting noise (Hood, 1998).

Some debate does exist in regards to whether theOAE or CM is a more appropriate test of cochlearfunction (Rance et al., 1999; Rapin et al., 2003).First, although OAE testing is time efficient andsensitive to outer hair cell function, OAEs may beabsent due to external or internal middle eardysfunction, such as otitis media, whereas the CMresponse will not be affected. Second, the CMresponse is more robust than the OAE response, andis less sensitive to cochlear damage than are OAEs(Rance et al., 1999; Rapin et al., 2003).

It is advantageous for the audiologist to collectas much auditory information as possible with thesepatients to avoid misdiagnosis. OAE and ABRtesting may be sufficient for screening purposes, butwith all of the technology available, more measuresare needed to differentiate true auditory neuropathyfrom retrocochlear/brainstem pathologies andthalamo/cortical disorders (Rapin et al., 2003).

Conclusions

Auditory neuropathy/dys-synchrony is a disorderfound in patients of all ages who present with normalouter hair cell function and abnormal/dys-synchronous auditory nerve function. They exhibitvarious degrees of hearing loss, and have significantdifficulty hearing in noise, far beyond what can bepredicted from the patient’s pure tone audiogram.

Although this disorder is hypothesized to belocalized to the level of the inner hair cells or theirsynapse with Type 1 auditory nerve fibres, thissuggested site of pathology cannot be ruled out asthere are no tests currently available for this purpose(Rance et al., 1999; Rapin & Gravel, 2003; Starr etal., 1996).

Therefore, it is necessary to have in place a setprotocol, which outlines the most sensitive yetefficient tests, both cost and time effective, for properidentification and confirmation of this disorder, forthose with and without risk factors to enable propermanagement.

Since AN/AD is characterized primarily ashaving normal outer hair cell function andabnormal/de-synchronous auditory nerve function,tests that are sensitive to both cochlear function andauditory nerve function are a necessity for properidentification of this disorder.

In order to screen for this disorder, the infantmust be given both the screening OAE and ABRtests. If only the first stage of the screening processis completed (OAEs), the disorder will remainundetected. Only with the combination of the twoscreening test results will an infant be identified.

Without a complete screen of the auditorypathway, an infant with auditory neuropathy/dys-synchrony may not be identified until that child failsto demonstrate expected developmental milestones,such as responding/startling to sound or localizationof sound. An older child may be at risk formisdiagnosis of either mental retardation or centralauditory processing disorder, due to hearing andlanguage difficulties despite normal outer hair cellfunction (Berlin et al., 2002).

Once a child has been referred for confirmationof auditory neuropathy/dys-synchrony, it isrecommended that more than just the OAE and ABRtests be used. Although these two tests do provide anassessment of the auditory pathway, specificallycochlear and neural function, it is recommended thattwo additional tests be included in the assessment.These include cochlear microphonics to assesscochlear function, and middle ear muscle reflexes toassess neural function.

The additional information that these two testswill provide to supplement the OAE and ABR testsresults will reduce the possibility of misdiagnosis,and help the audiologist to be confident that thepatient does indeed have auditory neuropathy/dys-synchrony.

References

Berlin, C.I., Bordelon, J., St. John, P., Wilensky, D.,Hurley, A., Kluka, E., & Hood, L.J. (1998).Reversing Click Polarity May Uncover AuditoryNeuropathy in Infants. Ear & Hearing. 19(1),37-47.

Berlin, C.I., Hood, L.J., Morlet, T., Rose, K., &Brashears, S. (2003). Auditory Neuropathy/Dys-Synchrony: Diagnosis and Management. MentalRetardation and Developmental DisabilitiesResearch Reviews, 9, 225-231.

Dolphin, W.F. (2004) Auditory Neuropathy andConfigured Hearing Loss: The Case for Two-Stage Screening. The Hearing Review

Hood, L.J. (2002). Auditory Neuropathy/AuditoryDys-synchrony: New Insights. The HearingJournal. 55(2), 10-18.

Hood, L.J. (1998) Auditory Neuropathy: What is itand what can we do about it? The HearingJournal, 51(8), 10-17.

94


Hood, L.J. (1998). Clinical Applications of theAuditory Brainstem Response. SingularPublishing Group, Inc. San Diego.

Infant Hearing Program (Ontario): Audiologicassessment protocol and guidelines.Implementation support document. (2002).

Jewitt, D., Romano, M., & Williston, J., (1970).Human Auditory Evoked Potentials: PossibleBrainstem Components Detected on the Scalp.Science, 167, 1517-1518.

Jewitt, D., & Williston, J. (1971). Auditory EvokedFar Fields Averaged From the Scalp of Humans.Brain, 94, 681-696.

Joint Committee on Infant Hearing, Year 2000position statement: principles and guidelines forearly hearing detection and interventionprograms (2000). American Journal ofAudiology, 9, 9-29.

Katz, J. (2002). Handbook of Clinical Audiology (5th

Ed) Lippincott, Williams & Wilkins. Baltimore:MA.

Norton, S., Gorga, M., Widen, J., Folsom, R.,Sininger, Y., Cone-Wesson, B., Vohr, B.,Mascher, K., & Fletcher, K. (2000).Identification of Neonatal Hearing Impairment:Evaluation of Transient Evoked OtoacousticEmission, Distortion Product OtoacousticEmission, and Auditory Brain Stem ResponseTest Performance. Ear & Hearing, 21(5), 508-528.

Rance, G., Beer, D. E., Cone-Wesson, B., Shepherd,R. K., Dowell, R. C., King, A. M., Rickards, F.W., & Clark, G. M. (1999). Clinical findings fora group of infants and young children withauditory neuropathy. Ear & Hearing, 20(3),238-252.

Rapin, I., & Gravel, J. (2003). “AuditoryNeuropathy”: physiologic and pathologicevidence calls for more diagnostic specificity.International Journal of PediatricOtorhinolaryngology, 67, 707-728.

Rhodes, MC., Margolis, RH., Hirsch, JE., Napp, AP.(1999). Hearing Screening in the NewbornIntensive Care Nursery: Comparison of Methods.Otolaryngology Head and Neck Surgery, 120,799-808.

Starr, A., Picton, T. W., Sininger, Y., Hood, L. J., &Berlin, C. I. (1996). Auditory neuropathy.Brain, 119, 741-753.

95

Copyright © 2005, Picado Goncalves, C.

Efficacy of thermal-tactile stimulation in dysphagia management

Picado Goncalves, C.M.Cl.Sc. (SLP) Candidate


This critical review examines the efficacy of thermal-tactile stimulation in dysphagia management.Study designs include: repeated measures design and ABAB single subject withdrawal casedesign. Overall, there is some evidence to support the effectiveness of thermal tactile stimulation;however, the evidence comes from studies that use healthy, normal volunteers. Therefore, it is notpossible to state directly that thermal tactile stimulation is an effective therapeutic technique indysphagia management. More experimentation is needed using persons with dysphagia.

Introduction

In the United States, it was estimated that eachyear, there were approximately 250,000 new cases ofindividuals who had a stroke, 30%-50% of theseindividuals also exhibited dysphagia (Rosenbek,Roecker, Wood & Robbins, 1996). A common signof dysphagia resulting from stroke is a delay intriggering of the pharyngeal swallow which can leadto an increased risk of aspiration or choking. Atherapeutic procedure that has been used for patientswith delayed pharyngeal swallow is thermal-tactilestimulation.

In thermal-tactile stimulation, also known asthermal stimulation or sensitization, the clinicianplaces a small mirror in ice until it is cold. Thechilled probe is then used to stroke either one or bothof the anterior faucial pillars 5 to 6 times (Rosenbek,Robbins, Fishback & Levine, 1991). The patient isthen asked to swallow.

Thermal stimulation is recommended for patientswho exhibit “delayed triggering of the swallowingreflex” (Rosenbek, et al., 1991, pg 1257). The termused to describe this delay is “Duration of stagetransition” (DST). DST refers to the “time betweenthe arrival of the head of the bolus at the posteriormargin of the ramus and the beginning of maximumelevation of the hyoid bone during the swallow”(Rosenbek, et al., 1996). A long DST is one of thecriteria needed to receive thermal stimulation(Rosenbek, et al., 1996). According to Logeman, thepurpose of thermal sensitization “is to heighten thesensitivity for the swallow in the oral cavity so thatwhen the patient voluntarily attempts to swallow, heor she will trigger a reflex more rapidly” (Rosenbek,et al., 1991 pg 1257).

More than 50% of Veterans Hospitals in theUnited States use some form of thermal stimulationas a technique to improve dysphagia (Rosenbek et al.,1996). However, data demonstrating theeffectiveness of this technique is limited.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theeffectiveness of thermal-tactile stimulation in

triggering a pharyngeal swallow. The secondaryobjective is to propose evidence-based practicerecommendations that can guide future research inrefining the method of thermal stimulation in order toobtain more precise results.

Methods

Search StrategyComputerized databases, such as EBM Review

(all), PubMed and Medline, were used to search forarticles using the following key words:

((thermal) OR (thermal stimulation) OR(thermal sensitization) OR(thermomechanical stimulation) OR(mechanical stimulation) OR (cold) OR(touch)) AND ((gustatory stimulation) ORtaste)) AND ((deglutition) OR (deglutitiondisorder) OR (swallowing disorder) OR(dysphagia)) AND ((anterior faucial pillars)OR (faucial pillars)).


Selection CriteriaStudies selected to be critically evaluated were

required to investigate the effectiveness of thermaltactile stimulation. Limits were not set on thedemographics of the participants.

Data CollectionThe articles that were critically evaluated had the

following experimental designs: repeated measuresdesign (7) and ABAB single subject withdrawal casedesign (1).

Results

Several studies have been conducted todetermine the effectiveness of thermal stimulation asa therapeutic procedure to improve a delayedpharyngeal swallow; however, the findings have notprovided a definite answer to this question.

The studies analyzed revealed that thermalstimulation does not play a role in triggering apharyngeal swallow. Rosenbek et al. (1991) studiedthe effects of thermal stimulation on patients who had

96

EFFICACY OF THERMAL-TACTILE STIMULATION IN DYSPHAGIA MANAGEMENT

a stroke, as well as its long-term effects ondysphagia. Long-term effects using this techniquefailed to be shown. Two out of three judges agreedthat two subjects had a decrease in DST after thermalstimulation was used; however, the amount ofaspiration and penetration did not change. Thisevidence leads to weak support for the effectivenessof thermal stimulation.

Two other studies looked at the effects ofthermal stimulation on healthy participants. Bove etal. (1998) and Ali et al. (1996) were interested indetermining the effects of a cold stimulus on thepharyngeal swallow. Both studies revealed that acold stimulus did not facilitate a pharyngeal swallow.

Other studies have shown that thermalstimulation resulted in an improvement in thepharyngeal swallow. The earliest data were providedby Lazzara et al. (1986), who observed that“stimulation improved triggering of the swallowingreflex in 23 of these 25 neurologically impairedpatients on swallows of at least one consistency”(Rosenbek, et al., 1996 pg. 226).

Rosenbek et al. (1996) conducted another studythat assessed the short term effects of thermalstimulation in patients who have had a stroke.Participants who received treatment had a shorterDST than participants who did not receive treatment.It should be noted however the authors only studiedthe effects of temperature (i.e. a cold stimulus) ontriggering a pharyngeal swallow. Therefore, thermalstimulation was effective in improving thepharyngeal swallow.

Two other studies looked at variables beyondeffects of temperature on the pharyngeal swallow.Kaatzke-McDonald et al. (1996) and Sciortino et al.(2003) investigated the effects of temperature, tasteand mechanical stimulation to the anterior faucialpillars. Both studies used healthy participants. Themain results of these studies were similar. Theapplication of cold stimulus to the anterior faucialpillars facilitated a pharyngeal swallow. Kaatzke-McDonald et al. (1996) observed that using solutionsof glucose, saline and distilled water did not producea significant effect in triggering a pharyngealswallow (p>0.05). However, Sciortino et al. (2003)observed a shorter duration of swallow when theanterior faucial pillars were stroked with a coldstimulus and a sour stimulus was presented(p=0.045).

Researchers were also interested in thephysiological mechanism of thermal stimulationwhich can provide insight to which variables arenecessary to trigger a swallow. Fujiu et al. (1994)conducted an experiment using healthy participantsand looked at glossopharyngeal evoked potentialsinduced by mechanical stimulation (i.e. using a warmrod) to the anterior faucial pillars. It was observedthat one third of the subjects reported “a desire toswallow” at least once during the experiment whichwas not influenced by the accumulation of saliva

(Fujiu , Toleikis , Logemann & Larson , 1994).Therefore, these findings suggest that touch aloneinfluenced the desire to swallow.

Chi-Fishman et al. (1994) reported similarresults. Cats were used to determine if a coldmechanical stimulus presented to the anterior faucialpillars (i.e. stimulating the glossopharyngeal nerve)could modulate a swallow produced by electricalstimulation of the internal laryngeal nerve (ILN).The rational was that simultaneous electricalstimulation of the ILN and IX can increase thefrequency of swallows; thus, a similar effect may befound if ILN was electrically stimulated while IXwas stimulated mechanically (i.e. room temperaturevs. cold temperature) (Chi-Fishman, Capra & McCall,1994). It was reported that mechanical stimulation ofthe IX along with electrical stimulation of the ILNwas capable of modifying the swallow response(p<0.01). However it made no difference whether thestimulus was room temperature or cold temperature.

Conclusions

According to the literature, in order to determinethe effectiveness of thermal stimulation, one needs tolook at a host of factors that is inherent in thestimulation technique.The overall protocol wassimilar in each experiment; a stimulus was presentedto the faucial pillars and then a response wasmeasured. However, the finer detail of the protocolvaried from study to study. The areas that were notconsistent were: the location on the faucial pillarsbeing stimulated, the method of stimulation (e.g.stroke vs. touch), bilateral vs. unilateral stimulationand amount of time between trials. The temperatureat the tip of the probe and the length of stimulation atthe faucial pillars are also important factors toconsider. Selinger et al. (1994) reported that by thetime the probe had been removed from ice andreached the faucial pillars, the probe had reachedminimal cold sensation levels. It was furtherobserved that six seconds after the probe had beenlifted from the ice, the temperature was perceived aswarm. (Selinger, Prescott & Hoffman, 1994).Therefore, by constructing a special probe thatspecifies the temperature at its tip, more accurateresults may be obtained.

Keeping these factors constant and onlymanipulating specific variables, it is possible tocompare the results and determine what factorscontribute to the triggering of the pharyngealswallow. By not controlling these factors, it becomesquite difficult to determine the aspect of theprocedure actually contributed to the triggering of thepharyngeal swallow.

Age and gender differences were found in thestudy conducted by Sciortino et al. (2003), thereforeit is important to consider the age and gender whenselecting subjects. This study was very wellconstructed and provided support to the effectiveness

97

EFFICACY OF THERMAL-TACTILE STIMULATION IN DYSPHAGIA MANAGEMENT

of thermal stimulation. However, the resultsobtained came from healthy, normal volunteers. Inorder to determine if this technique is an effectivetherapeutic procedure in dysphagia management, thisstudy needs to be replicated on individuals withdysphagia.

Finally, more research needs to be conducted ondiscovering the kinds of receptors located in the oralmucosa. Receptors in this area do not respond toevery temperature. Some receptors may respond tonegative degrees Celsius and others may respond topositive degrees Celsius. Therefore, it is important todiscover what temperature causes the receptors toreact. Furthermore, receptors in this area do notrespond to the same stimuli. Some may respond totemperature, others may respond to mechanicalstimulation, where as others may respond to taste.By looking at the physiology of the faucial pillarsand its receptors, it can provide information as tohow thermal stimulation can be improved.

Research in this area is very important becausethermal stimulation can potentially improve thepatient’s ability to swallow safely. As well, it canimprove the quality of life by allowing the patient toreturn to consuming foods that he or she enjoys.Thus, it is important to investigate the effectivenessof thermal-tactile stimulation as a treatment forindividuals with dysphagia.

References

Ali, G.N., Laundl, T.M., Wallace, K.L., deCarle, D.J.& Cook, .I.JS. (1996). Influence of ColdStimulation on the Normal Pharyngeal Swallow

Response. Dysphagia, 11, 2-8.Bove, M., Mansson, I. & Eliasson, I. (1998). Thermal

Oral-Pharyngeal Stimulation and Elicitation of Swallowing. Acta Otolaryngology, 118, 728-

731.Chi-Fishman, G., Capra, N.F. & McCall, G.N.

(1994). Thermomechanical facilitation ofswallowing evoked by electrical nervestimulation in cats. Dysphagia, 9(3), 149-55.

Fujiu, M., Toleikis, J.R., Logemann, J.A. & Larson,C.R. (1994). Glossopharyngeal evoked potentialsin normal subjects following mechanicalstimulation of the anterior faucial pillar.Electroencephalography & ClinicalNeurophysiology. 92(3), 183-95.

Kaatzke-McDonald, M.N., Post, E. & Davis, P.J.(1996). The effects of cold, touch, and chemicalstimulation of the anterior faucial pillar onhuman swallowing. Dysphagia.11(3), 198-206.

Rosenbek, J.C., Robbins, J., Fishback, B. & Levine,R.L. (1991). Effects of Thermal Application onDysphagia after Stroke. Journal of Speech andHearing Research, 34, 1257-1268.

Rosenbeck, J.C., Roecker, E.B., Wood, J.L. &Robbins, J. (1996). Thermal application reduces

the duration of stage transition in dysphagia afterstroke. Dysphagia. 11(4), 225-233.

Sciortino, K., Liss, J.M., Case, J.L., Gerritsen, K.G.& Katz, R.C. (2003). Effects of mechanical,cold, gustatory, and combined stimulation to thehuman anterior faucial pillars. Dysphagia. 18,16-26.

Selinger, M., Prescott, T.E. & Hoffman, I. (1994).Temperature Acceleration in Cold OralStimulation. Dysphagia, 9, 83-87.

98

Copyright © 2005, Pool, E.S.

Impact of animal assisted therapy on aggression inpersons with dementia of the Alzheimer’s type

Pool. Emily S.M.Cl.Sc. (SLP) Candidate


This critical review examines the effect of Animal Assisted therapy on patients with Dementia ofthe Alzheimer’s type (DAT). DAT is defined as: a syndrome of acquired, progressive, persistentdecline in memory, language and communication, personality, spatial ability, and cognition.Methodology used to study aggression and Alzheimer’s Disease (AD): between subjects, within-subjects and mixed designs. Clinical Symptoms of DAT include: confusion, wandering, agitation,fear, and reduced ability to engage socially. Patients in the later stages do not follow conversationsbut instead rely on intonation and word stress patterns as clues to meaning (Hopper, 2003).Institutionalized persons with DAT may experience confusion, fear, depression, overload andsocial isolation, especially if they are verbally disruptive and aggressive. Patients with DATbenefit from structured behavioural treatments that reduce demands on their impaired cognitiveabilities and capitalize on their spared abilities (Hopper, 2003). Dogs do not place high demandson their communication partners.

Introduction

Over the past decade, interest in animal therapyhas been a growing topic for assisting treatment withthe elderly. Especially of interest is the use of dogtherapy for Alzheimer’s patients to improve theirsocial skills and reduce aggressive behaviours. Thetopic of the current paper is reducing aggression inpatients with Dementia of the Alzheimer’s type(DAT) and the question to be answered is: is animaltherapy useful in reducing such aggression.

Dementia is defined as a syndrome of acquired,progressive, persistent decline in memory, languageand communication, personality, spatial ability, andcognition (Hopper, 2003). The Early Clinical stage inDAT lasts from two to four years and involves someimpairment in memory and communication. Socialinteraction remains relatively unaffected. In theMiddle Clinical stage, severe language andvocabulary restrictions begin to surface. Patientsbecome uninhibited in their conversation and have atendency to ramble. The Late Clinical stage in DAToccurs in the last one to three years of the disease. Inthis stage, agitation, fear and wandering increase.Patients do not follow conversations but instead relyon intonation and word stress patterns as clues tomeaning. In the late stages, individuals with DATare able to follow one step commands and are usuallyinstitutionalized at this point. Institutionalizedpersons with DAT may experience confusion, fear,depression, overload and social isolation, especiallyif they are verbally disruptive and aggressive. Effortsare being made to better understand and minimizethese negative effects of the condition.

It has been found that people with DAT benefitfrom structured behavioural treatments that reducedemands on their impaired cognitive abilities andcapitalize on their spared abilities (Hopper, 2003).Dog therapy fits this treatment or care model verywell. Dogs place low cognitive demands on peopleand can provide rewarding feedback to patients.Zisselmam, Rovner, Shmuely, and Ferrie (1996)examined the effects of pet therapy intervention withgeriatric psychiatry inpatients. They assignedsubjects to either an exercise control group or a pettherapy group. They reported a non-significanttendency for those who receive pet therapy to haveless irritable behaviour.

In 1998, Forbes conducted a systematicoverview of the literature on strategies to managebehavioural symptoms associated with Dementia ofthe Alzheimer type (DAT). Strategies such asplanned walking, music therapy and visual barriersand of importance for this paper, pet therapy, were allfound to: 1) foster improvements in reducingaggressive, agitated and disruptive behaviours, 2) toincrease socialization, 3) to increase abilities in self-care, and 4) to reduce both wandering and day-nightdisturbances. The studies Forbes surveyed reportedthat although there was evidence to support thebenefits for the use of these strategies, more researchneeded to be done to gather stronger evidence inorder to draw valid conclusions on whether or whichof these techniques worked.

A more recent study by McCabe, Baun, Speichand Agrawal (2002) observed the effect of a residentdog on problem behaviours of people with DAT in aspecial care unit. These researchers used the NursingHome Behaviour Problem Scale to document the

99

IMPACT OF ANIMAL ASSISTED THERAPY ON AGGRESSION IN PERSONS WITH DEMENTIA OF THE ALZHEIMER’S TYPE

behaviours of the residents. They compared thebehaviours of the residents that had a dog present forthe day shift versus the evening shift. The results ofthis study were that no significant improvementswere found amongst the night shift residents. The dayshift residents exhibited significantly fewer problembehaviours over the four weeks of the study. Theseresults supported the idea that there would be long-term therapeutic effects for people with DAT usingdogs.

Richeson (2003) examined the effects of animal-assisted therapy on agitated behaviours and socialinteraction of older adults with dementia. Richesonemployed the Cohen-Mansfield Agitation Inventoryand the Animal-Assisted Flow Sheet as measures .Fifteen participants from nursing homes participatedin the study for three weeks. Pre- and post-test resultsshowed significant decreases in agitated behavioursand significant increases in social interaction amongthose adults receiving the animal-assisted therapy.

Churchhill, Safaoui, McCabe and Baun (1999)also considered the effects of a therapy dog toalleviate agitation and desocialization for people withDAT. They looked at whether short-term exposure toa therapy dog as well as other calming interventionsfor persons with DAT. They found significantreductions in aggression and increased socializationbehaviours.

Curtright and Turner (2000) examined theinfluence of stuffed toy animals and live animals oncommunication. They compared language output andanimal based therapy. Surprisingly, they foundsimilar results for both stuffed and live animals. Thissuggests that perhaps animal therapy may not need tobe done with live animals, but that stuffed animalsare also effective. This may have been due to poorcontrolling for the interaction that happened with theexaminers.

Baun and McCabe (2003) also considered theeffects of companion animals for persons withDementia of the Alzheimer’s Type. These tworesearchers found that companion animals have thepotential to create new meaning and bring comfort topeople with DAT. They observed that whencaregivers plan activities with companion animalsaccounting for the functional abilities of people withDAT, agitation and aggression is reduced and socialinteraction may be increased. As a side benefit, theyalso discovered that there is a potential for reducedphysiological stress on caregivers of DAT patientsamong those caregivers who are involved with andthen become close to the therapy animals.

Although research in this area is relatively new,there is promising literature to suggest that animaltherapy will benefit persons living with Dementia ofthe Alzheimer type (DAT). Positive therapeutic

advantages may be experienced by the personsaffected with DAT.

Methods


PsycInfo, Medline, PubMed, and Cochrane Library,were searched using the following search strategy:

((Alzheimer’s disease) OR (Dementia) OR(DAT)) AND ((Animal) OR (dog) OR (pet))AND ((rehabilitation) OR (therapy) OR(treatment)).


review paper were required to investigate the impactof any type of animal interaction on the behaviour ofpeople living with DAT. No limits were set on thedemographics of research participants or outcomemeasures.


following types of articles congruent with theaforementioned selection criteria: critical review (1),pre-post tests (4), parallel-group control treatmenttrial (1).

Defining the IVThe Delta Society defines Animal-Assisted

Therapy (AAT) as “the use of animals in goal-directed interventions specifically designed toaddress the physical, social, emotional or cognitiveneeds of individuals or groups of individuals” (DeltaSociety, 2003). This definition is used to distinguishAAT from other services provided by animals, suchas animal-assisted activity (AAA), pet visitation,animal facilitated therapy, pet therapy, weekly dogvisitations, dog therapy (including touching, brushingand petting the dogs, as well as talking aboutanimals), and the permanent placement of a dog inthe resident care unit. Variable definitions of thetherapy that was being conducted with animals wereprovided and most researchers used the above termsinterchangeably.

Results

The research question was addressed byevaluating the strengths of six articles, examining themethods used to test this hypothesis. In this paper thefocus will now turn to evaluating the results reportedby these studies in terms of the statistical analysisthey used and their interpretations of the statisticalresults.

100


The systematic review by Forbes et al. (1998)narrowed down the selection of articles from 264 to45 using a rating tool they created. The rating toolmeasured design intervention, inclusion, attrition, andcontrol for confounders, method of data collection,and statistical analysis. Each category was dividedinto strong, moderate or weak based on acombination of these factors. They were attemptingto determine the effectiveness of several therapies forDAT on several outcomes (i.e. aggression, self-careetc.). Their study reported p values but did notinclude any raw data, making it very difficult tocompare with other studies. Because they reportedwhat they believed to be significant findings, but withonly the p values, and no mention of what sort oftests were done, what methods were used etc., it isdifficult to assume clinical significance of any of thetreatments reported.

Several other studies that were examinedindicated use of two-way analysis of variance(ANOVA). These studies all reported significantincreases in social interaction and/or reduction inaggressive behaviours. None of the studies reportedcontrol for investigator bias, drug interactions orobserver effects. Drug interactions are especiallyimportant when studying a group of people that areknown to be aggressive, because they most likely arerestrained with sedatives. No studies controlled fortime of medication taken, which could drasticallyaffect results. Four studies did report the results oftheir statistical tests; one study did not. This studymerely reported a main effect for presence of atherapy dog on the reduction of aggression by statingthe statistics on increased socialization. Since this isnot the reverse of aggression, results should also havebeen reported on the second hypothesis that animaltherapy would reduce aggression.

Two of the six studies included testing todetermine differences between groups (Mauchly’stest of sphericity and a normality check). Thisallowed them to be confident that parametric testscould be used and that there were no great variationsbetween groups that would affect the results.

One of the studies examined had such extremeflaws in the statistical analysis that this researcherdiscredits the results. This study reported to use apaired t-test and ANOVA as well as Chi-square forcategorical variables. Since they did not have anycategorical variables, they must have artificiallycategorized their subjects. Statistical significance wasnot found, but they continued to report a trendtowards significance. Hence, this researcherconducted power analysis on the data to find that theactual chance that results were due to themanipulation was 0.178%, and assuming a power of80% and an alpha of .05, they would need at least

617 subjects in order to show an effect. They thenwent on to discuss only women and found asignificant decrease in agitation among women.However, since they were using a mean for genderrather than one for women only (and incidentally didnot even get the percentage correct!), it must beconcluded that this is a very weak interpretation.

In conclusion, only three of the six studies thatwere reviewed are considered to be strong. It is theopinion of this researcher that these three studies domeasure what they claim to measure and are goodpapers on which to base the answer to the currentresearch question. All three of these studies showsignificant decrease in aggression following sometype of planned animal interaction and useappropriate measure to test this hypothesis.

Conclusion

Over the past decade interest in animal therapyhas been a growing topic for assisting treatment withthe elderly. Especially of interest is dog therapy forAlzheimer’s patients to improve social skills andreduce aggressive behaviours. Although research inthis area is relatively new, there is a strong body ofevidence to support that animal therapy will benefitpersons living with Dementia of the Alzheimer type(DAT). Positive therapeutic advantages occur for thepersons affected with DAT as well as theircaregivers.

Of 6 studies that were reviewed by this author,three were considered to be strong in term ofstatistical testing and methods used for analysis. It isthe opinion of this researcher that these three studiesdo measure what they claim to measure and are goodpapers on which to base the answer to the currentresearch question. All three of these studies showsignificant decrease in aggression following sometype of planned animal interaction among residents oflong term care facilities with Alzheimer’s Disease.Thus, it is my opinion that there is a strong body ofevidence to support clinical implementation ofanimal therapies.

One major factor that may have an impact onweakening my stance, is the fact that animal therapyhas been so poorly defined. This problem occurredacross all the studies and is relevant to my question inthe way we define the independent variable. TheDelta Society defines animal assisted therapy (AAT)as “the use of animals in goal-directed interventionsspecifically designed to address the physical, social,emotional or cognitive needs of individuals or groupsof individuals (Delta Society, 2003.) This definitionis used to distinguish AAT from other servicesprovided by animals, such as animal-assisted activity(AAA), pet visitation, animal facilitated therapy, and

101


pet therapy. Unfortunately, there is no consistencythroughout the literature to determine what term isbeing used to mean what type of intervention andmost researchers seem to use the termsinterchangeably. Over the course of my review, Ifound the terms: weekly dog visitations, dog therapy(cert. By Delta Society), Animal-assisted therapy(including touching, brushing and petting the dogs, aswell as talking about animals), and the permanentplacement of a dog in the resident care unit to be usedinterchangeably for the most part.

Despite this major problem with the definition ofAnimal Therapy, I support AAT as a valuabletreatment for aggression in people with DAT.Although AAT was poorly defined, all studies foundimprovements in aggression levels of people whowere exposed to dogs. However, these results arelimited to long-term care facilities, and are onlyrecommended as such. Since no difference wasfound based on the type of animal interaction,considerations such as funding may be important inchoosing what sort of a program to implement in longterm care facilities with people with Dementia of theAlzheimer’s type. Finally, I suggest that furtherinvestigation be done to compare the types of animaltherapies that were described to assess which typesare the most effective.

References

Baun and McCabe (2003). Companion Animals andPersons with Dementia ofthe Alzheimer’s Type:Therapeutic Possibilities. American BehavioralScientist Special Issue: Human-AnimalInteraction & Wellness, .47(1), 42-51.

Curtright and Turner (2002), The influence of Stuffedand Live Animals on Communication in aFemale with Alzheimer’s Dementia. Journal ofMedical Speech-Language Pathology, 10(1), 61-71.

Churchhill, Safaoui, McCabe and Baun (1999). Usinga Therapy Dog to Alleviate the Agitation andDesocialization of People with Alzheimer’sDisease. Journal of Psychosocial Nursing andMental Health, 37(4), 16-22.

Cohen-Mansfield, J., and Libin, A. (2004).Assessment of agitation in elderly patients withdementia: correlations between informant ratingand direct observation. International Journal ofGeriatric Psychiatry, 19, 881-891

Cohen-Mansfield, J. (1996). Conceptualization ofAgitation: Results based on the Cohen-MansfieldAgitation Inventory and the Agitation BehaviorMapping Instrument. InternationalPsychogeriatrics, 8(S3), 309-315.

Forbes (1998). Strategies for Managing BehaviouralSymptomatology Associated with Dementia ofthe Alzheimer’s type: a Systematic overview.Canadian Nursing Journal, 30(2), 67-86.

Haycox, J. (1984). A simple reliable clinicalbehavioural scale for assessing dementedpatients. Journal of Clinical Psychiatry, 45, 23-24.

Helmes, E., Csapo, K. & Short, J-A. (1987)Standardization and Validation of theMultidimensional Observation Scale for ElderlySubjects (MOSES). Journal of Gerontology, 42,395-405.

Kongable, L.G., Buckwalter, K.C., & Stolley, J. M.(1989). The effects of pet therapy on the socialbehaviour of institutionalized Alzheimer’sclients. Archives of Psychiatric Nursing, 3, 191-198.

McCabe, Baun, Speich and Agrawal (2002). ResidentDog in the Alzheimer;s Special Care Unit.Western Journal of Nursing Research, 24(6),684-696.

Ray, W., Taylor, J., Lichtenstein, M., & Meador, K(1992) The Nursing Home Behaviour ProblemScale (NHBPS). Journal of Gerontology, 47,M9-16.

Richeson, N. E., & McCullough, W. T. (2002). Anevidence-based animal assisted therapy protocoland flow sheet for the geriatric recreationaltherapy practice. American Journal of RecreationTherapy, 1(1), 25-31.

Richeson (2003). Effects of Animal-AssistedTherapy on Agitated Behaviours and SocialInteraction of Older Adults with Dementia.American Journal of Alzheimer’s Disease andOther Dementias, 18(6), 353-358.

Zisselmam, Rovner, Shmuely, and Ferrie (1996). APet Therapy Intervention with GeriatricPsychiatry Inpatients. American Journal ofOccupational Therapy, 50(1), 47-51.

102

Copyright © 2005, Price, A.M.

Evidence to support using parent-based intervention as acomponent of speech-language therapy for children

Price, A.M.M.Cl.Sc. (SLP) Candidate


This critical review investigates the impact of parent-based intervention as a component of speech-language therapy for children. Study designs include: multiple baseline design and experimentaldesigns. Overall, the review of the research supports the use of parent-based intervention forchildren with speech-language delays or difficulties. More research needs to be done to examinethe long-term effects of parent-based intervention, and to identify more specifically which childrenwould benefit the most from this type of treatment.

Introduction

There are a number of treatment options forspeech-language pathologists when treating childrenwith speech and language difficulties. One of theseoptions is using parent-based intervention (PBI). Inthis approach, parents are trained to provide speech-language support to their children using a variety oftechniques.

There is some uncertainty regarding the benefitsof PBI. On the one hand, it is suggested that parent-clinician partnerships are necessary to encouragechildren’s development (Gibbard, Coglan, &MacDonald, 2004). It is also acknowledged thatteaching parents to encourage their children’slanguage skills is helpful in enhancing generalizationof in-clinic therapy activities to the homeenvironment (Iacono, Chan, & Waring, 1998). On theother hand, there are a few noted disadvantages toparent-based intervention. Hemmeter and Kaiser (ascited in Iacono et. al., 1998) reported that the parentis put in the role of the instructor to the child, and thiswill upset the parent-child relationship. Anotherconcern is that some parents may not want to beinvolved in treatment of their child (Turnbull &Turnbull, 1982, as cited in Gibbard, 1994).

Objectives

Clinicians need to know that PBI is effectivebefore implementing this type of approach. Manyresearch studies have examined the effectiveness ofPBI as a component of speech-language therapy forchildren. The objective of this article is to criticallyevaluate the literature concerning the evidence tosupport using PBI as a component of speech-language therapy for children.

Methods


Psychinfo, PubMed, EBM, and Medline weresearched using the following search strategy:

((parent training) OR (parent intervention)OR (parent education)) AND ((child) OR(pediatric)) AND ((speech-language) OR(speech) OR (language) OR(communication)) AND ((delay) OR(disorder) OR (impairment)) AND((therapy) OR (treatment) OR(intervention)).


Selection CriteriaOnly studies that examined the effectiveness of

PBI on the speech-language abilities of children withspeech-language delays or difficulties were selectedfor inclusion in this review.

Data CollectionResults from the literature search produced the

following types of studies that met the selectioncriteria: multiple baseline design (1) andexperimental design (4).

Results

Two of the reviewed studies compared PBI witha no-intervention control group. McDade andMcCartan (1998) found that the PBI group madesignificant gains (p < .01) in expressive language incomparison with the control group. In all engagementstates (interactive, unitary, and unengagement), therewas not a statistically significant change in thecontrol group, and there were significant treatmenteffects found for the PBI group (p < .05). Thenumber of information-carrying words increased by

103

USING PARENT-BASED INTERVENTION AS A COMPONENT OF SPEECH-LANGUAGE THERAPY FOR CHILDREN

138% in the PBI group, and by 22% in the controlgroup (McDade & McCartan, 1998).

In Phase 1 of a study by Gibbard (1994)comparing a PBI group with a no-intervention group,the results revealed that the PBI group madesignificantly greater gains in expressive language (p< .01) when compared to the control group.

Phase 2 of the study by Gibbard (1994)compared a PBI group, an individual therapy group,and a parental control group who received training onnon-language related skills. Statistical analysisrevealed that the differences between the PBI groupand the individual group were not significant (p >.05) on expressive and receptive language variables,except for mean length of utterance (MLU). The PBIgroup made significantly greater gains in comparisonwith the parental control group (p < .05) onexpressive and receptive language variables. Theindividual group made significantly greater gains (p <.05) than the parental control group on somemeasures (MLU, Derbyshire-total scores) (Gibbard,1994).

Baxendale and Hesketh (2003) compared a PBIgroup (using the Hanen Parent Program (HPP)) withan individual therapy group. The study found thatchildren in both groups improved their expressiveand receptive skills by 73%. Comparison of languagescores and MLU scores between the two groupsrevealed no significant differences. For parentinteraction measures, and parent responses to childutterances, no significant differences were foundbetween the two groups at any assessment point. TheHPP was found to be more costly than the clinic-based therapy (Baxendale & Hesketh, 2003).

A similar study by Gibbard, Coglan, andMacDonald (2004) compared a PBI group with astandard care group (parent and child were seen on athree-month review and advice basis). Analysis of theresults using the Mann-Whitney U Test revealed thatthe PBI group did significantly better than thestandard care group (p < .05) on expressive andreceptive variables. When the results were analyzedusing ANCOVA, the PBI group did significantlybetter than the standard care group on expressive andreceptive language variables, with the exception ofthe estimation of vocabulary. The cost-effectivenessof PBI was found to have no significant increase incost per outcome gain over standard care (Gibbard et.al., 2004).

A study by Iacono, Chan, & Waring (1998),examined the effectiveness of PBI on a group ofchildren using a multiple baseline design. Adescriptive analysis was done on the results. In thestudy, three of the five subjects exhibited morefrequent productions of linguistic units. For two ofthe subjects a post hoc decision was made to examine

their vocalizations and gestures, and both subjectsexhibited increases. When the parent strategies ofeach mother were examined it was found that onlyone mother reduced the number of child-directedutterances she produced; the other mothers showedincreases. All mothers increased their use of models(i.e. reflection on child’s activity), and overall use ofspecific teaching strategies (i.e. strategies used toextend child’s utterance and elicit words) andreduced their use of directives (i.e. imperative orsuggestion for child on what to do) (Iacono et. al.,1998).

A methodological strength of these studies wasthat they used appropriate research designs based ontheir research questions. All of the studies used theappropriate statistical tests to analyze their resultsbased on the type of data, number of variables, andthe type of research question. Another strength ofthese studies was in the interpretation of the results.All of the studies correctly interpreted p values andmade conclusions regarding the results that seemedreasonable and justified.

These studies had some flaws in theirmethodology, research design, and interpretation ofresults. All of the studies failed to blind both thesubjects and the experimenters. Also, all of thestudies used convenience sampling in their selectionof subjects, and a self-selection bias may haveoccurred. The lack of blinding and use ofconvenience sampling may have been unavoidable inthe research design, and would not have skewed theresults to a great degree. Lastly, none of the reviewedstudies reported effect sizes which would have shownthe magnitude of the difference between the groupsthat was found. Effect sizes may not have beenreported because it was not a common procedure inthe previous research.

Conclusions

Overall, these studies examining theeffectiveness of PBI all reached similar conclusionsand revealed that PBI was effective compared to nospeech-language therapy, and equally as effective asindividual therapy.

Based on the literature review and the strength ofthe research, there is evidence to support using PBIas a component of speech-language therapy forchildren. PBI is a practice that should beimplemented as a component in the treatment ofspeech and language difficulties in children undercertain conditions. In particular, the use of PBIshould involve the setting of specific languageobjectives for families to have the most success(Gibbard, 1994). PBI also needs to be implementedwith families where the parents need help on using

104

USING PARENT-BASED INTERVENTION AS A COMPONENT OF SPEECH-LANGUAGE THERAPY FOR CHILDREN

the appropriate language facilitation strategies(Baxendale & Hesketh, 2003). It should be noted thatsome children may require a more controlled andindividualized approach to treatment, and PBI maynot be appropriate for them (Baxendale & Hesketh,2003). The results of the study by Baxendale andHesketh (2003), suggested that PBI was notappropriate for children with moderate to severelanguage impairments. PBI has been found to bemore costly than traditional clinic therapy in both ofthe reviewed studies that examined cost-effectivenessand families need to be chosen carefully to make surethat PBI is the best choice for them (Baxendale &Hesketh, 2003, Gibbard et. al., 2004).

More research needs to be done to examine thelong-term effects of PBI. Research needs to comparethe long-term effectiveness of PBI in comparison toother intervention approaches so that the mostbeneficial approach is chosen for use in clinicalpractice. Research regarding the use of PBI hasproven the approach to be effective and this approachshould be implemented into clinical practice. Whenclinicians are considering implementing PBI theyneed to consider the child’s level of severity, thechild’s characteristics, the families’ use of languagefacilitation strategies, and the cost of the program.Additional research should examine how to weightthese factors when determining whether or not to usePBI. As a therapy approach, PBI has been shown tobe very effective when chosen for the appropriatefamilies. This approach needs to be implemented as apart of speech-language therapy for children becauseit is not only effective but will help to treat manymore children who are in need of treatment.

References

Baxendale, J., & Hesketh, A. (2003). Comparison ofthe effectiveness of the Hanen ParentProgramme and traditional clinic therapy.International Journal of Language andCommunication Disorders, 39(4), 397-415.

Gibbard, D. J. (1994). Parental-based interventionwith pre-school language-delayed children.European Journal of Disorders ofCommunication, 29, 131-150.

Gibbard, D., Coglan, L., & MacDonald, J. (2004).Cost-effectiveness analysis of current practiceand parent intervention for children under 3years presenting with expressive language delay.International Journal of Language andCommunication Disorders, 39(2), 229-244.

Iacono, T., Chan, J., Waring, R. (1998). Efficacy of aparent-implemented early language interventionbased on collaborative consultation.

International Journal of Language andCommunication Disorders, 33(3), 281-303.

McDade, A., & McCartan, P. (1998). ‘Partnershipwith parents’ a pilot project. InternationalJournal of Language and CommunicationDisorders, 33(suppl), 556-561).

105

Copyright © 2005, Ramlalsingh, T.R.

Clinical measurement of loudness discomfort levels

Ramlalsingh, T.R.M.Cl.Sc. (Aud) Candidate


This critical review examines the viability of directly measuring patients’ loudness discomfortlevels by examining the variables that may affect its measurement in given protocols.Furthermore, it investigates whether such measurements are necessary or whether alternativemethods of obtaining these levels indirectly should be used. Overall research suggests that whilean existing algorithm can satisfactorily predict optimum SSPL90 for a majority of patients, it willnot do so for all patients. Thus, directly measuring LDLs in cases where it is possible may still bethe best practice; however, a single best practice protocol has yet to be identified.

Introduction

The level of sound at which a patient experiencesdiscomfort and will not accept listening to iscommonly referred to as his/her loudness discomfortlevel (LDL), also known as uncomfortable loudnesslevel (UCL or ULL), or threshold of discomfort (TD).Clinical assessment measures commonly includeprocedures that measure a patient’s LDLs for thepurposes of selecting the saturation sound pressurelevel (SSPL90) of his/her hearing instrument(Hawkins et al., 1987, Dillon & Storey, 1998, Bentler& Cooley, 2001).

The rationale behind using a patient’s LDLs toset the SSPL90 of the hearing instrument includes aneed to maximize the patient’s aided dynamic rangeto optimize audibility without compromisingintelligibility (from saturation), to avoid rejection ofthe hearing aid because of discomfort to loud sounds(Hawkins et al., 1987) and to prevent further hearingloss (Dillon & Storey, 1998). For reasons such asthese, there exists a need to obtain LDL measuresthat are both accurate and reliable (Bornstein &Musiek, 1993).

However, the task of obtaining such measures isdifficult, and is largely influenced by severalvariables if measured directly. Such variablesinclude psychophysical method, instruction set,signal type, signal duration, signal delivery, andauditory sensitivity (Beattie et al., 1980, Hawkins etal., 1987). In addition to this, measured LDLs shouldreflect real-life discomfort in order to be valid (Filion& Margolis, 1992, Munro & Patel, 1998).

An alternative method to directly measuringLDLs is proposed by Dillon & Storey (1998).Reasons for such an alternative include the difficultnature of obtaining reliable values directly,calibration issues when comparing LDL withSSPL90, limiting the measurement to one particularstimulus when setting the SSPL90 is to preventdiscomfort to all sounds, and no evidence showing

that the hearing instrument SSPL90 should equal apatient’s LDLs.

While the reasons for obtaining or estimatingLDLs are clear, it is less so as to which protocolwould be the most clinically viable and it is even lessevident if such measures should be obtained directlyat all.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regardingmeasurement protocols for conducting LDLs. Asecondary objective is to critically evaluate whetherdirect measurement is necessary, or whether analgorithm can be used to predict a patient’s LDLs.

Methods

Search StrategyComputerized databases, including MEDLINE-

OVID and CINAHL, were searched using thefollowing search strategy:

((loudness and discomfort and levels) OR(uncomfortable and loudness and level) OR(threshold and discomfort)).

No limitations were applied to these searches.

Selection CriteriaStudies included in this critical review paper had

to examine any LDL measurement techniques andprocedures, any variables related to its measurement,as well as alternatives to using this measurement inclinic for the purposes of fitting a hearing instrument.No limitations were placed on any factors that mayaffect LDL measurement, such as demographics ofresearch participants.

106

CLINICAL MEASUREMENT OF LOUDNESS DISCOMFORT LEVELS

Data CollectionResults of the literature search revealed two main

types of research designs: repeated measures andcrossover designs.

Results

Effect of Different Variables on LDL

Psychophysical MethodA single psychophysical method was not

demonstrated to be superior, but significantlydifferent LDLs were obtained between methods(Morgan et al., 1974, Hawkins et al., 1987, Bentler &Cooley, 2001). The method employed by Hawkins etal. (1987), yielded LDLs that were found to be morestable over time (4 dB shift over 4 days) whencompared to a Bekesy procedure from Walker andcolleagues (>20 dB shift over 4 days). In a previousstudy done by Morgan et al. (1974), a constantstimuli procedure was seen to produce more reliableLDLs than two other procedures (adjustment andtracking).

Instructional SetDifferent instructional sets resulted in

statistically significant LDL differences (Beattie etal., 1980, Hawkins et al., 1987). It was suggestedthat more stable and accurate LDLs would resultwhen the instruction set included the following:specifying a time period and criterion for judging theloudness of the signal (Beattie et al. 1980), clearlydefining the term “uncomfortable”, giving a clear yetsimple task to follow (where it is more concernedwith making loudness judgements rather than button-pushing), providing printed material showing thedifferent categories of loudness, and conveying theimportance and use of the test to the patient (Hawkinset al., 1987).

The wording of the instructions should elicitloudness judgements rather than quality judgements,(i.e. “uncomfortable” should be used rather than“annoying”) (Bornstein & Musiek, 1993). Inaddition, the clinician should be aware of stress andintonation verbal cues, as well as nonverbal cues,when instructing the patient on the task (Beattie et al.,1980).

Signal TypeDifferent frequency-specific stimuli (puretones,

one-third octave band noise, one-third octave bandfiltered speech centered around 250, 500, 1k, 2k, and4k Hz), did not result in statistically significantdifferences in LDLs. According to Dirks & Kamm,pulsed stimuli would prevent adaptation effects (ascited in Bornstein and Musiek, 1993). A generaltrend for LDLs to increase with higher frequencies

was noted (Beattie & Boyd, 1986, Hawkins, 1980,Morgan et al., 1974).

Similarly, different speech-like stimuli (wide-band noise, spondaic words, sentences) did not resultin any statistically significant differences in LDLs(Hawkins, 1980). Findings were consistent whendifferent recorded speech stimuli were used(Edgerton et al. 1980). No effect was found fordifferent-gendered talkers (Bentler & Nelson 2001).

The predictive nature between puretone LDLsand speech LDLs was studied to determine if theywould result in different values. When mean speechand puretone (500, 1k, 2k, 3k Hz) LDLs werecompared, no statistically significant differenceswere found. Although very weak (p<.01), astatistically significant predictive relationship wasobserved between puretone and speech LDLs, but alarge standard error (SE) shows that it does soinaccurately (SE ~9.5 dB) (Beattie & Boyd, 1986). Amore recent study suggests that speech LDLs can bemore accurately predicted from puretone LDLs ifmeasured at 750, 1.5k, and 3k Hz (Bentler & Nelson,2001).

Signal DeliveryNo statistically significant differences were

found when two different transducers (insert phonesv.s. headphones) were used to obtain LDLs (Valenteet al., 1997). It was shown that reliable LDLs canalso be obtained in soundfield (Bornstein & Musiek,1993). Significant differences in LDLs were foundwhen speech stimuli were delivered via monitored-live voice across different clinicians (p<0.01)(Sammeth et al., 1989).

Signal DurationAn inverse relationship between signal duration

and LDLs was revealed, showing that patients willtolerate louder sounds if they are shorter in duration(Fortune & Scheller, 2000). A statistically significantcorrelation was found between clinically measuredLDLs and discomfort ratings for longer durationsounds (such as traffic), but could not be found forshorter duration sounds (Munro & Patel, 1998).

Auditory SensitivityGreater LDL values were observed for

increasing hearing losses (thresholds) across severalstudies (Edgerton et al., 1980, Valente et al. 1997,Bentler & Cooley, 2001). Furthermore, it wasrevealed that ears with flat losses have a greatercorrelation between thresholds and loudness(p<0.001) than those with sharply sloping losses(Sammeth et al., 1989). A general trend for LDLvalues to remain fairly constant for hearingthresholds up to 45 dB HL, and gradually increase

107


with increasing puretone thresholds was noticed(Edgerton et al., 1980).

Contrary to this common trend, a more recentstudy revealed that normal hearing individualsdemonstrated significantly higher LDLs than thosewith hearing impairments. This contradiction may beexplained by the fact that hearing impaired ears arethought to experience greater loudness summation(due to increased critical bandwidth), and previousstudies used puretone stimuli rather than complexstimuli, which may result in lower LDL measures(Bentler & Nelson, 2001).

Age & Gender EffectsNo statistically significant differences were

found between LDLs obtained from males andfemales. Similarly, no significant differences wereshown to exist between LDLs obtained from adultsand children (7-14 yrs.) (Kawell et al., 1988).

Alternative Method to Direct MeasurementIn a study that compared outcomes from

clinically measured LDLs to those predicted by analgorithm using patient hearing thresholds, it wasseen that although the measured LDLs improvedaccuracy of predicting the optimum SSPL over thealgorithm, they did not do so significantly. In fact,SSPL was demonstrated to be almost as wellpredicted from 3FA thresholds (500, 1k, 2k Hz), andis easier to measure (Storey et al., 1998). Thepredicted SSPL was deemed acceptable by 86% ofthe subjects (n=29) in a laboratory evaluation, and63% of the subjects (n=32) in a field experiment.

Reliability and Validity

Test-Retest ReliabilityConsistent with other findings, within session

and between session variability using speech stimuliwas found to be relatively low (Sammeth et al.,1989), showing that LDLs can be measured quitereliably. Test-retest levels were found to be within 5-10 dB in almost 95% of the subjects (Edgerton et al.,1980, Beattie & Boyd, 1986).

However, it has been demonstrated that intra-and intersubject variability is another matter, and canvary as a function of procedure employed, instructionset, signal type and frequency (Hawkins, 1980,Hawkins et al., 1987, Bornstein & Musiek, 1993,Valente et al., 1997). Edgerton et al. (1980), showedthat a large degree of intersubject variability in LDLsfor a given threshold can be found, and thatprediction from thresholds alone could not beaccurate. Reported results from Sammeth et al.(1989), support such findings.

External ValidityFilion & Margolis (1992), found clinical LDL

judgements to be poor predictors of real-lifeimpressions of discomfort. On the contrary, Munro& Patel (1998), showed that when the SSPL90 wasset to levels determined by clinically measuredLDLs, subjects did not express real-world auditorydiscomfort, and were more likely to experiencediscomfort to environmental sounds of longerdurations when the output exceeded these levels.Clinically measured LDLs predict real-life auditorydiscomfort, at least for longer duration sounds suchas wind or traffic noise (p<0.01).

Predictive ValidityWhen incorporated into the fitting, clinically

measured LDLs only slightly improved the accuracyof predicting optimum SSPL; rms error was 5.9 dB.The theoretical formula from Dillon & Storey, (1998)was found to be almost as good a predictor ofacceptable SSPL, with an rms error of 6.3 dB (Storeyet al., 1998).

Conclusions

While research has consistently demonstrated theimportance of obtaining accurate, reliable, and validmeasures of LDL for the purposes of selecting thehearing instrument’s SSPL90, no specific “bestpractice protocol” has been identified. Given theevidence described in the preceding paragraphs, thefollowing is an attempt to describe which variablesshould be included in such a protocol.

The psychophysical method and instruction setsuggested by Hawkins et al. (1987), may provide agood means of obtaining reliable LDLs because of itsclear instructions, simple-to-follow task, it gives thelistener the purpose of the task and loudness criterionfor judging, provides categories above and below thetarget category (uncomfortable), and is moreconducive to judging loudness than quality.Furthermore, the listener can read the instructionsfrom a paper, along with the examiner, and theexaminer provides no further interpretations.

While evidence may seem to support the use ofspeech-like (complex) stimuli (i.e. close correlationbetween longer duration sounds and LDLs, and useof meaningful stimuli), it may be more useful todetermine frequency-specific LDLs simply becauseof the way a hearing instrument is fit (frequency-by-frequency, or by channels). If speech-like stimuli isto be used, its presentation should be standardizedand recorded, not monitored-live voice. Eithergendered talkers should result in similar LDLs.

LDLs obtained using frequency-specific stimulicentered at 750, 1.5k, 3k Hz may actually be good

108


predictors of real-life situations (complex stimuli) ifall frequencies cannot be obtained. As well, it can becompleted in less time and be less fatiguing to thepatient. Although puretone stimuli may be too shortin duration if pulsed (which may reveal elevatedLDLs), it may avoid adaptation effects.

Depending on the protocol of any given clinic,measurement of LDLs using insert phones orheadphones should not result in significantdifferences. Given what the field has come to realizeabout the advantages of testing with insert phones, itsuse may be considered first, but will not result ininappropriate levels if headphones must be used forone reason or another. Soundfield testing may alsobe used if necessary.

Although there is some evidence to suggest thatit would not be worth measuring LDLs for thepurposes of selecting the SSPL of a hearinginstrument, and can be almost as well predicted using3FA hearing threshold data, the authors haverecognized that because there will be patients that dodiffer with respect to the predicted SSPL, evaluationand fine-tuning is still absolutely essential (Storey etal., 1998). Given this and the high intersubjectvariability identified by many authors, it would be inthe best interest of the patient if LDLs can beobtained via direct measurement. Because concernshould be about the individual patient, suchvariability is alarming; for the same hearingthresholds a wide range of LDLs can be possible.

However, if accurate measures are not possibleto obtain (such as with very young children, ordifficult-to-test patients), an alternative method maybe used to predict a patient’s LDLs. It has beendemonstrated that such a method will predict anacceptable SSPL setting for a majority of patients,and does not require age or gender considerations.

In the words of Valente et al. (1997), “Theavailable technology does not appear to provideclinicians with any justifiable reason to simplycomplete an audiogram and allow software to predictthe LDL using algorithms based on average groupdata” (pg.66). Until evidence can demonstrategreater strength of using predicted LDLs to select theSSPL90, clinicians should be aware that directlymeasuring LDLs is advisable, but should beconducted in a standardized manner based on theevidence.

References

Beattie, R.C., & Boyd, R.L. (1986). Relationshipbetween pure-tone and speech loudnessdiscomfort levels among hearing-impairedsubjects. Journal of Speech and HearingDisorders, 51, 120-125.

Beattie, R.C., Svihovec, D.A., Carmen, R.E., Kunkel,H.A. (1980). Loudness discomfort level forspeech: Comparison of two instructional sets forsaturation sound pressure level selection. Earand Hearing, 1, 197-205.

Bentler, R.A. & Cooley, L.J. (2001). An examinationof several characteristics that affect theprediction of OSPL90 in hearing aids. Ear &Hearing, 22, 58-64.

Bentler, R.A. & Nelson, J.A. (2001). Effect ofspectral shaping and content on loudnessdiscomfort. Journal of the American Academy ofAudiology, 12, 462-470.

Bornstein, S.P. & Musiek, F.E. (1993). Loudnessdiscomfort level and reliability as a function ofinstructional set. Scandinavian Audiology, 22,125-131.

Dillon, H. & Storey, L. (1998). The NationalAcoustic Laboratories’ procedure for selectingthe saturation sound pressure level of hearingaids: Theoretical derivation. Ear & Hearing, 19,255-266.

Filion, P.R., & Margolis, R.H. (1992). Comparison ofclinical and real-life judgements of loudnessdiscomfort. Journal of the American Academy ofAudiology, 3, 193-199.

Edgerton, B.J., Beattie, R.C., Wides J.W. (1980).Loudness discomfort levels of hearing-impairedlisteners using speech material. Ear andHearing, 1, 206-210.

Fortune, T., Scheller, Tom. (2000). Duration,compression, and the aided loudness discomfortlevel. Ear & Hearing, 21, 329-341.

Hawkins, D.B. (1980). The effect of signal type onthe loudness discomfort level. Ear & Hearing, 1,38-41.

Hawkins, D.B., Walden, B.E., Montgomery, A.,Prosek, R.A. (1987). Description and validationof an LDL procedure designed to select SSPL90.Ear & Hearing, 8, 162-169.

Kawell, M.E., Kopun, J.G., Stelmachowicz, P.G.(1988). Loudness discomfort levels in children.Ear & Hearing, 9, 133-136.

Morgan, D.E., Wilson, R.H., Dirks, D.D. (1974).Loudness discomfort level: selected methodsand stimuli. Journal of the Acoustical Society ofAmerica, 56, 577-581.

Munro, K.J. & Patel, R.K. (1998). Are clinicalmeasurements of uncomfortable loudness levelsa valid indicator of real-world auditorydiscomfort? British Journal of Audiology, 32,287-293.

109


Sammeth, C.A., Birman, M., and Hecox, K.E.(1989). Variability of most uncomfortable anduncomfortable loudness levels to speech stimuliin the hearing impaired. Ear & Hearing, 10, 94-100.

Storey, L., Dillon, H., Yeend, I., Wigney, D. (1998).The national acoustic laboratories’ procedure forselecting the saturation sound pressure level ofhearing aids: Experimental validation. Ear &Hearing, 19, 267-279.

Valente, M., Potts, L.G., and Valente, M. (1997).Differences in intersubject variability of loudnessdiscomfort levels measured in sound pressurelevel and hearing level for TDH-50P and ER-3Aearphones. Journal of the American Academy ofAudiology, 8, 59-67.

110

Copyright © 2005, Scollie, S., Seewald, R., Sinclair-Moodie, S., Cornelisse, L., Bagatto, M., & Beaulac, S.

The Desired Sensation Level (DSL) method in 2004:DSL m[i/o] version 5.0

Scollie, S., Ph.D.1,2, Seewald, R., Ph.D.1,2, Sinclair-Moodie, S., M.Cl.Sc.1,Cornelisse, L., M.Sc.2, Bagatto, M., M.Cl.Sc.1, Beaulac, S., B.E.Sc.3

1 The National Centre for Audiology, The University of Western Ontario, London, Ontario2 School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario3 dspFactory, Waterloo, Ontario4 Canadian Language and Literacy Research Network, London, Ontario

The Desired Sensation Level (DSL) Method for the electroacoustic selection and fitting of hearinginstruments for infants, children and adults has been revised on several occasions to keep pacewith changing technology. The computer-assisted implementation of the DSL method was firstreleased in 1993 (DSL 3.1) and was updated to DSL[i/o] for wide-dynamic range compression in1996. Version 5, the most recent version, has been enhanced for multi-channel, multi-slope digitaldevices and to address new verification protocols in hearing instrument fitting. The poster willdescribe these enhancements, which include 1) a multi-channel, multi-slope input/output strategyfor use with newer technology, 2) a technique for hearing instrument fitting utilizing ABR data, 3)new RECD data, and 4) ‘range’ of targets for adult fittings.

111

Copyright © 2005, Sharma, R.

Do audiologic rehabilitation efforts have apositive impact on coping and communication?

Sharma, R.M.Cl.Sc. (Aud) Candidate


This critical review examines the effects of audiologic rehabilitation efforts on coping andcommunication of older adults with hearing loss. Study designs include: randomized controlledtrials, quasi-experimental designs, and group experimental designs. Overall, research supports thepositive impact of audiologic rehabilitation efforts on coping and communication of older adults;however, issues in research design as well as the clinicians’ own views impact the acceptance andthe use of audiologic rehabilitation efforts in the clinical environment and as such, must beaddressed.

Introduction

Audiologic rehabilitation (A/R), which was onceconsidered at the center of the field of audiology, hasgone through many changes in the recent past. As aresult, the provision of A/R in the clinicalenvironment has been challenged and A/R has movedinto the periphery of many audiological practices.

During the past decade, A/R in general and theuse of hearing aids in particular, has been the subjectof growing interest and activity. One reason for thisis the realization that for many hearing-impairedindividuals, the fitting of hearing aids is not a simpleand straightforward road to improvingcommunication problems caused by the hearing loss(Arlinger, 2000). In this respect, the current focuson hearing aids as the predominant form ofintervention is inadequate for the majority of olderpeople with hearing impairment (Hickson et al,2003). Kochkin (1996) reported that 18% of peoplewho own aids do not wear them, 17% of aids arereturned for credit, and only 53% of hearing aid usersexpressed satisfaction with their hearing aids. A/Rbeyond that of hearing aid provision alone is clearlywarranted (Kochkin, 1996).

Personal perception of handicap is reduced aftera short-term A/R program, or after being fit withhearing aids (Weinstein, 1996). However,economical constraints have become evident in manyhealth-care systems, increasing the demands forproviders of A/R to show what benefits the patientsobtain after various kinds of intervention and at whatcost, i.e., cost-benefit analysis (Abrams et al., 2002).As well, the application of new technology to A/Rhas also brought about a need to evaluate the impactof intervention strategies on the services provided toparticipants in A/R programs.

To justify A/R as a clinical procedure, as well aspart of audiological curricula, A/R must be proven tohave a positive impact on coping and communication

on individuals with hearing loss. This wouldfacilitate acceptance of A/R services by third-partyinsurers and health care administrators.

Objectives

The primary objective of this paper is tocritically evaluate existing literature regarding theimpact of A/R efforts on coping and communicationby adults with acquired hearing loss.

Methods



((audiologic rehabilitation) AND ((auralrehabilitation) OR (aural rehab) OR(communication courses).



review paper investigated the impact of any type ofA/R efforts on coping and communication ofindividuals with hearing loss. No limits were set onthe demographics of research participants or outcomemeasures.


following types of articles congruent with theaforementioned selection criteria: randomizedcontrolled trial (RCT) (2), experimental groupdesigns (2) and quasi-experimental design (1).

112

IMPACT OF AUDIOLOGIC REHABILITATION EFFORTS ON COPING AND COMMUNICATION

Results

With respect to the literature reviewed, moststudies showed that A/R efforts did have a positiveimpact on individuals.

Randomized Controlled TrialsBeynon and colleagues (1997) evaluated the

benefits of a communication course for first timehearing aid users. Individuals fitted with hearing aidsfor the first time were randomized into two groups, atreatment group and a control group. After the initialfitting, patients first wore the hearing aid for sixweeks. Those individuals assigned to the treatmentgroup then entered a four-week communicationcourse. Hearing handicap was measured by means ofa self-rated questionnaire (Quantified Denver Scaleof Communication (QDS)) at the time of hearing aidfitting and 13 weeks later. Reduction in handicap, asmeasured by the change in QDS, was significantlygreater for the treatment group than for the controls.

Abrams et al’s (1992) randomized controlledstudy found similar results. The effect of a groupcounseling-based communication course in additionto amplification (group 1) was compared to patientsreceiving hearing aid only (group 2) and those withneither hearing aids nor A/R. The effect on self-perceived handicap was measured by the change inHHIE pre- and post-intervention. For bothexperimental groups, hearing handicap was reducedas a function of intervention whereas there was nochange in hearing handicap for the controls.

A limitation of these studies is the use of self-assessment scales as outcome measures. Althoughthese inventories may represent the best estimates ofthe clients’ performance, reactions, and feeling, inday-to-day communication, the inventories are farfrom perfect. For example, their content does not tapmany aspects of interactive communication, they arebased on no accepted model of communicationbreakdown, and they are not designed to assesschange per se and may do it ineffectively(Montgomery, 1994). Also, the use of inventoriesassumes literacy and motivation on the part of theclient, which is not always the case.

Experimental Group DesignsKricos et al (1992) examined the efficacy of a

communication-training program for elderly adultswith hearing impairment. An experimental groupreceived a 4-week communication-training programwhereas the control group received no training.Results revealed significant reduction in self-perceived hearing handicap and slight but significantimprovement in speech recognition ability for allsubjects.

Kricos et al (1996) examined a controlled trial ofactive listening training to determine the efficacy ofA/R using measures of speech recognition, self-perceived hearing handicap, and psychosocial status.Two intervention procedures were evaluated. Pre-and post-treatment speech recognition measures,psychosocial assessments, and hearing handicapscales systematically evaluated the effectiveness ofthe procedures. Active listening training was foundto be an effective rehabilitation procedure improvingboth speech recognition and psychosocialfunctioning.

A limitation of these studies is that they arebased on group means. They tend to ignoreindividual differences, which are readily apparentfrom variability among subjects within groups.Concluding that a treatment is effective pertains tothe group mean and does not imply that everyindividual within a group responded in the samemanner.

Quasi-Experimental DesignHickson and colleagues’ (2003) study, looked at

the benefits of communication education programs.The experimental group attended a communicationeducation program whereas the control groupreceived a communication assessment but nointervention. Significant improvements were foundin the experimental group in terms of knowledgeabout communication changes with age and aboutstrategies to maintain communication skills comparedto the control groups. Ten years later, theexperimental group was still found to be coping andmanaging well relative to the controls.

A limitation of this study is the samplepopulation was restricted to those individuals whoread newspapers and/or read notice boards in senior’scenters. A second limitation is the subjective mannerin which individual were assigned into control andtreatment groups skewing the results in favor ofindividuals interested in the communication programand aware of the study.

Conclusions

General consensus appears to be that A/R effortshave a positive impact (Abrams et al, 1992; Beynonet al, 1997; Hickson et al, 2003; Kricos et al, 1996).The following recommendations may help move A/Rback to the center of the profession as it once was.

One recommendation is methodological flawsthat exist in research designs be addressed. Forinstance, the development and agreement of outcomemeasures that reflect communication performance ineveryday listening and speaking situations isessential.

113

IMPACT OF AUDIOLOGIC REHABILITATION EFFORTS ON COPING AND COMMUNICATION

A second recommendation is aimed at clinicians.To maintain A/R as an integral part of the profession,it is just as important for clinicians to implement A/Rinto their clinics as it is for research to show thepositive results of A/R efforts.

A third recommendation is for educationalinstitutions to continue to teach future audiologiststhe importance of A/R and provide training in A/R.

These recommendations may help to ensure thatA/R remains a vital and integral part of the field ofaudiology as it was once, and as it should be.

References

Abrams, H., Hinath-Chisolm, T., Guereiro, S., &Ritterman, S. (1992). The Effects of InteventionStrategy on Self-Perception of HearingHandicap. Ear and Hearing, 13(5), 371-77.

Abrams H, Hnath-Chisolm T., & McArdie, R.(2002). A cost-utility analysis of adult groupaudiologic rehabiliation: Are the benefits worththe cost? Journal of Rehabilitation Research &Development, 39(5), 549-57.

Arlinger, S. (2000). Can We EstablishInternationally Equivalent Outcome Measures inAudiological Rehabilitation? Ear and Hearing,21(Suppl 4), 97S-99S.

Beynon, G., Thornton, F., & Poole, C. (1997). Arandomized, controlled trial of the efficacy of acommunication course for first time hearing aidusers. British Journal of Audiology, 31, 341-54.

Demorest, M., & Erdman, S. (1994). Research inAudiological Rehabilitation: The Challenges.Journal of the Academy of RehabilitativeAudiology, 27(Monograph Supplement), 291-371.

Gagne, J.-P. (1998). Reflections on evaluativeresearch in audiological rehabilitation.Scandinavian Audiology, 27 (Suppl. 49), 69-79.

Gagne, J.-P. (2000). What Is Treatment EvaluationResearch? What Is its Relationship to the Goalsof Audiological Rehabilitation? Who Are theStakeholders of this Type of Research? Ear andHearing, 21(Suppl 4), 60S-73

Gagne, J.-P., Hetu, R., Getty, L., & McDuff, S.(1995). Towards the development of paradigmsto conduct functional evaluative research inaudiological rehabilitation. Journal of theAcademy of Rehabilitative Audiology, 28, 7-25.

Hickson, L., & Worall, L. (2003). Beyond hearingaid fitting: improving communication for olderadults. International Journal of Audiology,42(Suppl 2), 2S84-91.

Kochkin, S. (1996). MarkeTrak IV: 10 Years trendsin the hearing aid market - has anythingchanged? The Hearing Journal, 49(1), 23-34.

Kricos P, Holmes A. (1996). Efficacy ofaudiological rehabilitation for older adults.Journal of the American Academy of Audiology,7, 219–29.

Kricos, P., Holmes, A., & Doyle, D. (1992).Efficacy of a communication training programfor hearing impaired elderly adults. Journal ofthe Academy of Rehabilitative Audiology, 25, 69-80.

Montgomery, A. (1994). Treatment Efficacy inAdult Audiological Rehabilitation. Journal ofthe Academy of Rehabilitative Audiology,27(Supplement), 317-36.

Weinstein, B. (1996). Treatment efficacy: Hearingaids in the management of hearing loss in adults,Journal of Speech Hearing Research, 39(5),S37-S45.

Weinstein BE. (1997). Outcome measures in thehearing aid fitting/selection process. TrendsAmplification, 4, 117–37.

114

Copyright © 2005, Skarakis-Doyle, E., Dempsey, L., & Lee, C.

Identification of discourse comprehension impairments

Skarakis-Doyle, E., Ph.D.1, Dempsey, L., M.Cl.Sc.1,2, Lee, C., Ph.D.3

1School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario2Doctoral Program in Rehabilitation Science, The University of Western Ontario, London, Ontario3School of Occupational Therapy, The University of Western Ontario, London, Ontario

Two new measures of language comprehension, the Joint Story Retell (JSR) and the ExpectancyViolation Detection Task (EVDT) designed for preschoolers were evaluated in this investigationfor the purpose of identification of language comprehension impairments in young children.Results demonstrated that children previously identified with language impairments performedsignificantly more poorly on these two measures than children in the same age range who weredeveloping language normally. Additionally, taken together the JSR and EVDT correctlyclassified 85% of the study’s participants according to their original group assignment, languageimpaired or normally developing. Thus, these measures are sensitive to language comprehensionimpairments in young children and may be used with confidence in the early identification ofchildren with language comprehension impairments.

115

Copyright © 2005, Sunney, C.A.

Cochlear implants and optimizing speech perception

Sunney, C.A.M.Cl.Sc. (Aud) Candidate


This critical review examines which preoperative measures dictate which individuals will adaptmost quickly and optimally to their implants. Study designs include: quasi-experimental designs,case control, and cohort study. Duration of deafness and speech performance pre-implant appearto be the most influential candidacy criteria in terms of postoperative speech performance and theadaptation process required for postlingually deaf adults to adjust maximally has been recognizedto be between 12 and 24 months however, the collective interaction between multiple variablesaffecting post-implant success has yet to be investigated.

Introduction

A number of factors must be addressed whencochlear implantation is being considered as atreatment option for adults with severe to profoundsensorineural hearing losses (acquired postlingually)who do not benefit from standard amplification.Unlike other clinical interventions, such as gettingprescription glasses to correct near-sightedness,getting a cochlear implant (CI) typically requiressubstantial learning and adaptation before the usercan obtain maximum perceptual benefit (Svirsky, etal., 2004). It cannot be predicted how much benefit,in terms of speech recognition, a person will receivefrom a CI. Nevertheless, several factors appear to besignificant contributors. Thus, assessing candidacy isof utmost importance in determining whichindividuals would be more likely to utilize theirimplants optimally.

Candidacy criteria for CI-ation have evolved insynchrony with speech processing technology (Davidet al., 2003). The current criteria differ from earlierguidelines that required both higher pure tonethresholds and poorer aided speech discriminationscores for candidacy (David et al., 2003). Forpostlingually deafened adults, the current criteria forimplantation require speech reception to be less than40% of words in the best aided condition (Copeland& Pillsbury, 2004). This often translates into 10%correct responses in open-set (no contextual or visualcues) single-word testing (Copeland & Pillsbury,2004).

Whatever the limitations that may hinder speechperception upon initial stimulation with a CI, itappears that perceptual adaptation does take placeand is largely successful, with no significant evidenceof enduring preconceptions. However, thisadaptation process can take several months or evenyears. Duration of deafness and speech performancepre-implant appear to be the most influentialcandidacy criteria in terms of postoperative speech

performance. Potential rehabilitative measures tofacilitate pre-implant speech performance maycontribute to post-implant success. The developmentof alternative signal processing and rehabilitationprocedures to facilitate and increase the speed of theadaptation process may result in important increasesin the quality of life of some CI recipients over thefirst few months or years after CI-ation (Svirsky et al,2004). Further research is needed with respect tocandidacy issues governing successful post-implantation speech performance.

Objectives

The purpose of this paper is to address thequestion: which pre-implantation criteria are the bestpredictors of successful post-implantation speechperformance. In other words, what preoperativemeasures dictate which individuals will adapt mostquickly and optimally to their implants?

Methods

Search StrategyComputerized databases, including PsychInfo,


((cochlear implant) OR (cochlearimplantation)) AND ((speech perception)OR (speech recognition) OR (speechcomprehension)) AND ((adults) OR(postlingual adults)).



review paper were required to investigate thecandidacy criteria or technological variables whichbest predict the postoperative speech recognitionabilities of postlingually deafened adults who have

116

COCHLEAR IMPLANTS AND OPTIMIZING SPEECH PERCEPTION

received CIs. Limits were set on the age of researchparticipants as well as communication preference, butnot for other demographic variables or outcomemeasures.

Preoperative measures, the number ofparticipants, the time interval over which subjects areevaluated, the stimuli used and the tests employedwere all methodological considerations in examiningthe predictors of optimal speech perception in CIusers.


following types of articles fitting with theaforementioned selection criteria: quasi-experimentaldesign (8), case control (2), and cohort study (2).

Results

Preoperative candidacy criteriaIn a quasi-experimental comparison of published

and composite data sets including 808 CI users,Blamey et al. (1996) found that duration of deafnesshad a strong negative impact on the auditoryperformance of postlingually deafened adult implantusers. Age at onset of deafness had little effect onperformance up to age 60, while age at implantationhad a slight negative effect (Blamey et al., 1996).Duration of implant had a positive impact onperformance and etiology had a weak effect onperformance (Blamey et al., 1996).

Rubenstein et al. (1999) aimed to determine theeffects of preoperative speech reception onpostoperative speech recognition with a CI. Theyfound that duration of deafness and preoperativesentence recognition are both significant predictors ofword recognition with a CI and can account for 80%of the variance in word recognition.

In the study by David et al. (2003), whichexamined the impact of speech coding strategy on thespeech perception performance in severe andprofound postlingually deafened adults, open-setspeech recognition sequences revealed significantimprovements in word and sentence scores asinnovative technology applied new speech codingstrategies. Analysis of covariance was performed todetermine whether duration of deafness andpreoperative aided sentence recognition, in additionto pure tone averages, could alter the differences inspeech perception scores measured between speechcoding groups. Analysis of covariance confirmed thatthese selection variables did not change therelationship of the differences observed betweenspeech coding strategies. Subgroup analysis ofprofoundly deafened patients supported this. Thus,while duration of deafness and preoperative sentence

recognition were shown to have an impact on speechperception skills, the particular speech codingstrategy did not seem to have a significant effect onadult CI users.Duration of Adaptation

Oh et al. (2003) evaluated the long-term speechperception of cochlear implantees and compared thedeveloping auditory performance patterns ofprelingual children and postlingual deaf adults. Inthe postlingual adults, the average results did notimprove further after 2 years. The data for thepostlingual adults were subgrouped according to theduration of deafness (short-term, < 5y, long term,>5y). In the short-term group, the speech perceptionperformances recovered at a faster rate and showedgreater improvements within 1 year afterimplantation (71% performance level at 12 months)than the long-term group. The long-term groupshowed smaller improvements in K-CID (Koreanversion of Central Institute of the Deaf test) score anda plateau of a 27% performance level was onlyachieved after 2 years.

In one case control design, Gomaa et al. (2003)evaluated the validity of the previously reportedpredictive index for postoperative CI performance,based on preoperative duration of deafness, andspeech recognition. They found that postoperativeperformance as measured by consonant-nucleus-consonant word scores had an inverse relationshipwith the duration of deafness, and a directrelationship with the preoperative performance onCID sentence recognition tests.

Svirsky et al. (2004) evaluated CI users in aquasi-experimental design. This showed thatalthough implant users performend more poorly thannormal-hearing listeners, they also showedsignificant learning and adaptation over time andachieved nearly normal performance after someexperience with the CI.

In a 10 year longitudinal study, Hildesheimer etal., (2001) studied 27 adults and 35 children whoeach completed 4 speech perception tests. Theycompared long-term speech perception improvementsexperienced after cochlear implantation. Resultsshow that average open-set score results of adultswere similar to those of children (Hildesheimer et al.,2001). Those adults with 6 months to 1 year of deviceuse reached their maximum performance on open-settests (Hildesheimer et al., 2001).

Difficulties in Research DesignsThe research design and outcome measures used

determine their generalizability to the greaterpopulation of adult CI users. Randomly controlledtrials (RCTs) using a large, uniform samplepopulation, tested both preoperatively and

117


postoperatively with outcome measures reflective ofreal world speech recognition are ideal, but may notbe possible. In the methodological review of theabove mentioned studies, it was suggested thatdouble-blind randomized trials be employed.However, the double blind RCTs in this particulararea of interest is difficulty. While clinicians may beblinded , it is not possible to blind the subjectsbecause any changes made to the mapping of theelectrodes would be immediately perceivable to thesubject. Also, one of the principles of RCTs is theassumption that subjects are randomly selected froma larger population of cochlear implanted adults.However, given the already small population size ofcochlear implanted adults, random selection ofsubjects from within this population could amount toa very small sample size The statistical power andgeneralizability of a research design is increased by agreater number of participants in the study. For thisreason, many studies use convenience samples inorder to evaluate as many patients as possible.

Conclusions

We now have high levels of control overresponse patterns in the auditory nerve, which in turnoffers the potential to reproduce normal auditoryprocessing more closely than was previously possible(Wilson et al., 2003). Despite this, many researchershave documented that there is an initial discrepancybetween the stimulation patterns provided by a CIand the listeners’ expectations of how speech shouldsound, which, in the case of postlingually deafenedCI users, would be expected to be stored in thepatients’ long-term memory (Svirsky et al., 2004).There are many factors contributing to this, andrecommendations to resolve these issues are the focusof this paper.

Svirsky et al. (2004) illustrate that unlike otherclinical interventions, such as getting prescriptionglasses to correct near-sightedness (which, moreoften than not, results in immediate benefit), getting aCI typically requires substantial learning andadaptation before the user can obtain maximumperceptual benefit.

Despite the early difficulties that may limitspeech perception upon initial stimulation with a CI,studies suggest that perceptual adaptation does takeplace and is, for the most part, successful, with nosubstantial indication of residual biases (such as abasalward shift or other types of frequency shifts)once the adaptation process is over (Svirsky et al.,2004). However, this adaptation process can takeseveral months or even years.

The adaptation process required for postlinguallydeaf adults to adjust maximally to a CI has been

accredited to be between 12 and 24 months(Hildesheimer et al., 2003; Svirsky et al., 2003). Ithas also been suggested that at least part of this post-implantation adaptation is related to changes inspeech sound labeling, a process whereby the listenermodifies his/her expectations concerning theperceptual patterns associated with different speechsounds (Svirsky et al., 2003). This process may befurther may be facilitated if comprehensiverehabilitative training programs are made availablepostoperatively.

It has been demonstrated that two significantpredictors of speech perception ability with implantsare preoperative sentence recognition and duration ofdeafness (David et al., 2003). It has been suggestedthat preoperative residual speech recognition acts as a"trophic factor" that protects the spiral ganglion and/or the central auditory pathways from degeneration(Gomaa et al., 2003). Taken together, these twovariables account for approximately 80% of speechrecognition scores postoperatively (Rubenstein et al.,1999). Thus, predictability of CI outcome is possibledepending on the preoperative duration of deafnessand speech recognition abilities (Gomaa et al., 2003).Nonetheless, these variables cannot entirely explainthe differences in speech perception scores measuredbetween speech coding groups (David et al., 2003).

It is highly recommended that other variables betaken into consideration to generate a more accurateprediction of postoperative speech recognitionperformance. It is thus necessary to understand otherpossible predictors of outcome, such as lip-readingability, nature of and age at onset of deafness, use ofa hearing instruments, cognitive skills andrehabilitative training post-implantation (Oh et al.,2003).

There are many areas of cochlear implantationthat, with further investigation, may provide parallelimprovements in speech recognition abilities forimplant users. Stimulation with bilateral implantshas provided important advantages for many patients,including head shadow benefits, and binauralsummation and binaural squelch or both for somepatients (Wilson et al., 2003). Further investigativeefforts in this area may indicate better ways to gainbenefits from binaural implants. Another area thatshould be the focus of some future studies is to findpredictors of the rate and speech coding strategy willprovide the individual with maximal perceptualbenefit (Skinner, 2003). Wilson et al., suggest thatfuture research efforts may also bring aboutapplications of intramodiolar implants, with theaccompanying possible advantages of reducedstimulus levels (and power consumption), increasedspatial specificity of neural excitation, and a largernumber of stimulus sites. It is essential that attention

118


is directed to discovering how a combination ofbehavioral responses in addition to analysis ofintracochlear responses to stimulation on theelectrodes might make clinical fitting moreconstructive than using behavioural responses alone(Skinner, 2003). These future research efforts areexpected to bring with them an improvement in thespeech perception ability of future implant users.

With the recent advances in speech processingstrategies and the anticipated improvements inimplant technology as well as clinical fittings, morerigorous speech recognition test batteries may berequired to quantify these advantages. Skinner(2003) makes the insightful recommendation that therelation of speech recognition to the combined effectsof electrode position, intracochlear neural responses,processor fitting parameters, cognitive and verbalskills, cause of hearing loss, and biographical factorsmay present important goals on how to providepatients with maximal speech perception benefit fromtheir cochlear implants.

References

Blamey, P., Arndt, P., Bergeron, F., Bredberg, G.,Brimacombe, J., Facer, G., Larky, J., Lindstrom,B., Nedzelski, J., Peterson, A., Shipp, D., Staller,S., & Whitford, L. (1996). Factors affectingauditory performance of postlingually deafadults using cochlear implants. Audiology &Neuro-Otology, 1(5): 293-306.

Chute, P.M., Parisier, S.C., & Kramer, S.F. (1984).Assessing candidacy for cochlear implants: II.Hearing Rehabilitation Quarterly, 9(3), 13-16.

Collison, E.A., Munson, B. & Carney A.E. (2004).Relations Among Linguistic and CognitiveSkills and Spoken Word Recognition in AdultsWith Cochlear Implants. Journal of Speech,Language, and Hearing Research, (47),496–508.

Copeland, B.J., & Pillsbury, H.C. (2004). CochlearImplantation for the Treatment of Deafness.Annual Review of Medicine, 55: 157-167.

David, E.E., Ostroff, J.M., Shipp, D., Nedzelski,J.M., Chen, J.M., Parnes, L.S., Zimmerman, K.,Schramm, D., & Seguin, C. (2003). SpeechCoding Strategies and Revised Cochlear ImplantCandidacy: An Analysis of Post-ImplantPerformance. Otology & Neurology,24(2), 228-233.

Gantz, B.J., Turner, C.W. (2003). Combiningacoustic and electrical hearing. TheLaryngoscope, 113, 1726-1730.

Gomaa N.A, Rubinstein J.T, Lowder M.W, Tyler R.S& Gantz B.J. (2003). Residual speechperception and cochlear implant performance in

postlingually deafened adults. The Ear &Hearing, 24(6), 539-44.

Hildesheimer, M., Teiltelbaum, R., Segal, O., Tenne,S., Kishon-Rabin, L., Kronenberg, Y., &Muchnik, C. (2003). Speech perception results- the first 10 years of a cochlear implantprogram. Scandinavian Audiology, 30(52), 39-41.

Oh, S., Kim, C., Kang, E., Lee, D., Lee, H., Chang,S.O., Ahn, S., Hwang, C., Park, H., & Koo, J.(2003). Speech Perception after CochlearImplantation over a 4-Year Time Period. ActaOto-Laryngologica, 123(2), 148-153.

Radcliffe, D. (1994). Window to the world ofhearing: Cochlear implants in children. TheHearing Journal, 47(6), 13-24.

Rubinstein J.T., Parkinson W.S., Tyler R.S. & GantzB.J. (1999). Residual speech recognition andcochlear implant performance: effects ofimplantation criteria. American Journal ofOtolaryngology, 20(4), 445-52.

Skinner, M.W. (2003). Optimizing cochlear implantspeech performance. The Annals of Otology,Rhinology & Laryngology, 112(9), 4-13.

Svirsky MA, Silveira A, Neuburger H, Teoh S-W &Sua´rez H. (2004). Long-term AuditoryAdaptation to a Modified Peripheral FrequencyMap. Acta Otolaryngology, 124, 381-386.

van Dijk, J.E., van Olphen, A.F., Langereis, M.C.,Mens, L.H.M., Brokx, J.P.L., & Smoorenburg,G.F. (1999). Predictors of cochlear implantperformance. Audiology, 38(2), 109-116.

Wilson, B.S., Lawson, D.T., Muller, J.M., Tyler,R.S., & Keifer, J. (2003). Cochlear Implants:Some likely next steps. Annual Reviews ofBiomedical Engineering, 5, 207-249.

Zwolan, T.A., Collins, L.M., Wakefield, G.H. (1997).Electrode discrimination and speech recognitionin postlingually deafened adult cochlear implantsubjects. Journal of the Acoustical Society ofAmerica, 102(6), 3673-3685.

119

Copyright © 2005, Theurer, J.A., Bihari, F., Barr, A.M., & Martin, R.E.

Oropharyngeal stimulation with air-pulse trainsincreases swallowing frequency

Theurer, J.A., M.Cl.Sc.1,2, Bihari, F., B.Sc.3, Barr, A.M., B.M.Sc.2,Martin, R.E., Ph.D.2,4

1Doctoral Program in Rehabilitation Science, The University of Western Ontario, London, ON2School of Communication Sciences and Disorders, The University of Western Ontario, London, ON3Clinical Neurological Sciences, EEG Department, London Health Sciences Centre, London, ON4Department of Physiology and Pharmacology, The University of Western Ontario, London, ON

While previous research has suggested that sensory stimulation applied to the faucial pillars canfacilitate swallowing, the range of stimuli that is effective in facilitating swallowing remainsunclear. We sought to determine whether oropharyngeal air-pulse stimulation would facilitateswallowing in healthy subjects. Preliminary results from four subjects showed that oropharyngealair-pulse stimulation evoked an irrepressible urge to swallow, followed by an overt swallow asverified by laryngeal and respiratory movements. Moreover, air-pulse stimulation was associatedwith a significant increase in swallowing frequency. These findings in healthy adults suggest thepossibility that oropharyngeal air-pulse stimulation may have clinical utility in dysphagiaindividuals who experience delayed triggering of the swallow reflex.

120

Copyright © 2004, Thornton, B.

Is there evidence to support using parent report as a screeningtool for identifying children with speech and language delay?

Thornton, B.M.Cl.Sc. (SLP) Candidate


This critical review examined four articles for evidence concerning the using of parent report as ascreening tool for identifying children with speech and language delay (SLD). Overall, researchsupports the use of parent report for identifying children with SLD; however, systematic review ofsaid literature revealed liabilities deficiencies in methodology and interpretation of results,potentially affecting outcomes. These concerns are discussed and recommendations for practiceare presented.

Introduction

With the movement towards evidence-basedpractice in health professions, there is increasedpressure on speech-language pathologists (SLPs) tomake clinical decisions that comply with currentresearch findings. Identifying children with speechand/or language delay (SLD) and then prioritizingthose who require treatment is a daily task required ofclinicians. The use of screening tools, such as parentreport measures, can theoretically help in thisdecision making; these tools could save time, moneyand resources (materials and people) allowing formore efficient service because SLPs would not berequired to spend time on a full speech-languageassessment where unnecessary (i.e. those childrenwho passed a screening). However, before wereplace the traditional clinical evaluation with suchparent screenings we must examine the specificityand sensitivity of screenings tools; using screeningssimply because they can be implemented quicklydoes not ensure they will produce valid and reliableresults. The clinical significance of low specificity ofa test includes potentially misidentifying normallydeveloping children as below age-appropriateexpectation; the clinical significance of lowsensitivity values includes potentially missing thechildren who should be appropriately identified asdelayed. Each of these situations has serious social(peer relationships, acceptance, etc.), financial(misuse of resources, long term costs of delayeddevelopmental skills such as education oremployment opportunities, personal independence,etc.), and psychological (stigma of therapy,diagnostic labeling, or lack thereof; self-esteem; etc.)implications. Therefore, it is necessary to ensureprofessional confidence in these measures before wecan implement them in our practices. This paperreviewed current research in order to resolve ifevidence exists to support the use parent report as a

screening tool for identifying and prioritizingchildren with SLD.

Objectives

The objectives of this paper were to criticallyevaluate existing literature regarding parent report asa screening tool for identifying children with SLDand propose ev idence-based prac t icerecommendations based on findings.

Methods

Search StrategyComputerized databases, including PsychInfo,

CINAHL, EBM Reviews, and PubMed, weresearched using the following search strategy:

parents and speech disorders OR parents andlanguage disorders OR screening anddevelopment OR parent report and languageOR parent report and speech OR parentconcern and language OR parent concernand speech OR parent screening andlanguage OR parent screening and speech.


Selection CriteriaStudies were selected for this critical analysis

based on the following criteria: they discussed parentreport as a measure of speech and/or language delayand compared it to another form of clinicalevaluation. Studies that examined parent report withrespect to specific speech and/or language relateddisorders, such as autism and ADHD, were excluded.

Results

Three of the articles reviewed supported the useof parent report as a method for identifying childrenwith SLD. The fourth article reported the neither

121

USING PARENT REPORT AS A SCREENING TOOL FOR IDENTIFYING CHILDREN WITH SPEECH & LANGUAGE DELAY

parent screening or structured screening againstwhich it was compared resulted in high enoughspecificity or sensitivity values to warrant clinicalsignificance. However, critical analysis revealed thatthese findings may not be as rigourous as suggested.The results of the critical analysis will now bediscussed.

Analysis of MethodologyOn the whole, the methodology of each study

was poor. The primary problem concerned themeasures against which parent report was compared:psychometrics and norming of the outcomesmeasures were poor and/or lacked standardizationthemselves. For example, one author employed a testnormed on a very different population from thatwhich was investigated. Additionally, if we are notconfident that the outcome measures actuallymeasured what they were intended to measure, we donot know how to interpret the results of comparisonsbetween them and parent screening tools. Whilemany of the outcome measures were and continue tobe considered standard clinical practice, making thestudies very practical from a clinical perspective,they were not and continue not to be standardizedmeasures; many leave much to be desired from astatistical viewpoint. Measures against which theparent screening tools are compared need to be morerigourous in their psychometric qualities to ensurethat we are validating the screeners against measuresknown to be valid and reliable themselves.

Other common flaws in methodology includedvague procedures and sampling issues, specificallysmall or homogenous sample populations. Forexample, one study only examined 64 children fromWyoming while another only included children froma research subject pool from the University ofWashington. Replicating such studies would provedifficult given unclear procedures and withoutreplication, we cannot validate findings. Further,weak sampling precludes the ability to generalizefindings to other populations, inhibiting theimplementation of evidence-based practice becauseany findings are evidence only for that specific groupof people. This, therefore, prevents any potentialcontribution the study might make to the evidencebase of research.

The Ideal DesignComparing parent screening results to standard

clinical practice outcomes seems to be an appropriateway to determine validity of parent report as a meansfor identifying children with speech and languagedelay. However, future studies need to examinelarger numbers of more representative samples.Research done on small samples in Wyoming or

England cannot be generalized to the commonpopulation of North America; more systematic andlarger-scale investigations need to be conducted.Furthermore, measures against which the parentscreenings are compared need to be more rigourousin their psychometric qualities. We need to ensurethat we are validating the parent report againstmeasures that are valid and reliable themselves.Without this, no parallel between standard screeningtools/assessment measures and parent report can bemade. Lastly, the ideal design should includeprocedures that are more clearly delineated than thosein the current review. This would ensure replicationof research is possible and that the evidence basecould be furthered more confidently.

Analysis of Results and InterpretationsWhile most of the researchers employed

appropriate statistical analyses (e.g. they useddiscriminant analysis for associational questions),their interpretations were often vague or incorrectlypresented. For example, one author presentednumerical data but failed to clarify what variableshad been analyzed to produce such results. Anotherauthor incorrectly stated that results were significantwhen in fact the reported p value was above the valuetypically associated with significant. Resultspresented in manners such as these examples, leavereaders with little confidence in the data reported.The implication of flawed results and interpretation istwofold: (1) readers are likely to disregard anyfindings; and (2) potentially valuable findings willnot be incorporated into practice, thus impedingevidence-based practice. Thus, on this basis, it isdifficult to accept the current research on parentreport as a screener for identifying children withSLD.

Recommendations

Based on critical analyses of each study’smethods, results, and findings, it is recommendedthat due to the inconclusive evidence andshortcomings in research, traditional clinicalevaluations should remain standard clinical practice;such evaluations may incorporate parent report, butshould not be replaced by parent screenings.

Of the studies reviewed, only one reported clearstatistical significance and discussed the clinicalsignificance; two others were vague in their resultsand one presented potentially misleading findings assome values were inappropriately interpreted. Thefourth study reported that neither the parent-ledscreening tool nor the structured screener againstwhich it was compared resulted in specificity andsensitivity values high enough to warrant clinical

122

USING PARENT REPORT AS A SCREENING TOOL FOR IDENTIFYING CHILDREN WITH SPEECH & LANGUAGE DELAY

significance. Generally, more rigourous analyses areneeded in order to have confidence in results and topractically apply findings. Furthermore, all fourstudies suggest further research be completed andthat future investigations might examine larger andmore diverse samples. Also, one study went so far asto suggest the field of study might benefit fromgovernment involvement in order to systematicallytrack and screen all children, a system comparable toOntario’s Infant Hearing Program where all infantsare screened for audiological problems soon afterbirth. It is clear then, that current evidence itself isinconclusive; therefore, traditional clinical evaluationshould remain standard clinical practice. Suchpractice may incorporate parent report, but should notbe replaced by parent screenings.

In summary, it is my recommendation that thecurrently available literature is not strong enoughwith respect to methodology and analyses, to provideevidence for using parent report as a screening toolfor identifying children with SLD. At this time, moreresearch is needed. Such research should, assuggested by the reviewed literature, include largerand more diverse samples, use stronger outcomemeasures, and more thorough interpretation ofresults. However, there are limitations to the aboverecommendations that include the potentiallyincomplete selection of research articles for review.As such, the recommendations presented in this papermight be considered in light of this limitation. Futureinvestigation of the validity and reliability of parentreport should help clarify if parent report can standalone as a screening tool for the identification ofchildren with SLD; whether it is best used inconjunction with other measures, or whether it is notappropriate for screening at all.

References

Dale, P.S. (1991). The validity of a parent reportmeasure of vocabulary and syntax at 24 months.Journal of Speech and Hearing Research, 34,565-571.

Glascoe, F.P. (1997). Parents’ concerns aboutchildren’s development: Prescreening techniqueor screening test? Pediatrics, 99, 522-528.

Klee, T., Carson, D.K., Garvin, W.J., Hall, L., Kent,A., and Reece, S. (1998). Concurrent andpredictive validity of an early language screeningprogram. Journal of Speech, Language, andHearing Research, 41, 627-641.

Laing, G.J., Law, J., Levin, A., and Logan, S. (2002).Evaluation of a structured test and a parent ledmethod for screening for speech and languageproblems: Prospective population based student.British Medical Journal, 325, 1152-1154. (page1-5 online at www.bmj.com)

123

Copyright © 2005, Ustynsky, T.

The impact of oral language delays on literacy development

Ustynsky, T.M.Cl.Sc. (SLP) Candidate


This critical review addresses whether or not children with specific oral language delays are at riskfor later literacy problems and if so, whether these children should receive priority speech andlanguage services to prevent this future impairment. The research studies include prospective,longitudinal and retrospective-prospective, longitudinal, correlational designs. Based on thecritical review, there is strong evidence to suggest that overall, children with oral language delaysare at risk for later literacy problems. However, further research needs to be conducted in order toidentify the specific oral language delay for which priority speech and language services ismerited.

Introduction

Over the past decade, the health care system hasbeen re-structured and is now working from apreventative framework. The goal is to identifywhich individuals are at risk for a specificimpairment and to treat them before the problemescalates. A specific issue that has arisen in the fieldof speech-language pathology is the relationshipbetween oral language delays and literacyimpairments.

An oral language delay may be defined as animpairment in the comprehension and/or productionof a spoken, written and/or other symbol system.This disorder can effect the form, content and/orfunction of language (ASHA cited in Paul, 2001).Adequate language skills may be seen as thefoundation for later literacy achievement. Thecomprehension of written text is dependent upon thedevelopment of linguistic knowledge used tounderstand speech (Paul, 2001). Thus, currentresearch is concerned with the negative effects thatlanguage impairments may have on later linguisticdevelopment.

Along with oral language delays, literacydifficulties can also have both immediate and long-term effects on the individual. In particular, theinability to effectively receive and process printedtext could have a disabling impact on the individual’sacademic, social and emotional success. Therefore,the relationship between these two variables is animportant issue to address because early detectionand intervention of children with oral languagedelays may prevent future literacy impairments fromoccurring.

Objectives

The primary aim of this paper is to criticallyevaluate the existing literature addressing the impactof oral language delays on literacy development. Thesecondary aim is determine whether or not a specifictype of oral language delay should be given priorityspeech and language services to prevent this futureimpairment.

Methods

Search StrategyThe research articles were found using a

computerized database search, including PubMed,Medline and Cochrane Library. The following keyterms were used:

((Language delay) OR (language disorder)OR (speech delay) OR (speech disorder)AND ((literacy delay) OR (readingdisability) OR (writing disability)).

The search was limited to articles published inEnglish between 1990 and 2004.

Selection CriteriaStudies that were selected for inclusion in this

critical review paper examined the relationshipbetween any oral language delay and later literacydevelopment. The selected articles were not limitedaccording to the demographics of the researchsubjects or the outcome measures of the studies.

Data CollectionThe literature search yielded studies that

employed prospective, longitudinal, correlationaldesigns (3) and one that employed a combinedretrospective-prospective, longitudinal correlationaldesign (1).

124

THE IMPACT OF ORAL LANGUAGE DELAYS ON LITERACY DEVELOPMENT

Results

Impact of Oral Language Delays on LiteracyDevelopment

Bird et al (1995) were concerned with whetheror not persistent literacy problems were found only inchildren with widespread language deficits. Theresearchers found that subjects who presented withexpressive phonological impairments had moredifficulty performing phonological awareness andliteracy tasks (p < .001) than subjects with no historyof phonological impairments. In addition, subgroupanalyses comparing the literacy skills of subjects withpure phonological disorders to subjects withphonological disorders plus additional languageimpairments did not reach significance. Therefore,both the subgroups displayed equally poorperformance on the literacy tasks.

The study conducted by Catts (1993) addressedwhether or not children with speech-languageimpairments were at a higher risk of readingdisabilities than were children with no history ofspeech-language impairments. The researcherreported that children with language impairmentswere at an increased risk for reading disabilities (p <.01) when compared to non-impaired subjects. Incontrast, the relationship between speechimpairments and literacy abilities was found to benon-significant (p > .05).

Catts (1993) also hypothesized that thestandardized and nonstandardized language measuresadministered in kindergarten would be related to firstand second grade reading achievement. It wasreported that when reading was assessed in terms ofword recognition, phonological awareness and rapidautomatized naming were the best predictors ofreading outcomes. This conclusion was supported bymoderate correlations between these two measuresand reading outcomes.

Felsenfeld et al (1994) examined thecorrelational relationship between performance onselected cognitive-linguistic variables measured inchildhood and adult educational and occupationaloutcomes for individuals with and without a historyof moderate phonological/language disorders. It wasreported that subjects with moderate phonologicaldisorders performed significantly more poorly thanthe control subjects on tests of cognitive-linguisticabilities. Also, the strength of association betweenearly articulation skills and adult language measureswas moderate to good (r values between .50 - .75).

Felsenfeld et al (1994) also analyzed if thepresent educational and occupation status of adultswho had a moderate phonological/language disorderin childhood was different from that of adults whodid not have this impairment. The statistical analysis

showed significant Chi-Square (X2 > 3.84) andPearson correlation (r = .60) results. Therefore,subjects with speech delays in childhood were morelikely to experience poor educational andoccupational outcomes than subjects with no historyof speech impairments.

Leitao and Fletcher (2004) proposed thatsubjects who presented with non-developmentalspeech errors would continue to perform more poorlythan subjects with developmental speech errors interms of their literacy skills. The researchers foundthat when compared to subjects with developmentalspeech impairments, the subjects with non-developmental speech impairments were significantlymore likely to have weak phonological awarenessskills (p = 0.04) and reading comprehension abilities(p = 0.037).

Overall, these research findings are supported byrigorous studies. First, all of the researchersemployed appropriate methodologies. For instance, alongitudinal research design was suitable because inorder to answer the research question the researcherswere required to measure changes over an extendedperiod of time. Also, all of the studies used a controland experimental group. This lends further supportto the findings because the researchers were able todetermine that the results were actually due to thevariable in question and not due to some externalfactor. Next, a majority of the studies administeredstandardized measurement tools and outcomemeasures that were valid and reliable. This practicesupports the research findings in that the testsmeasured what they claimed to measure and that thetests would yield similar results if repeated on thesame subjects regardless of the number of examinersor the timing of administration.

The research findings are further justified by thesuitability of the statistical analyses. First, all of thestudies employed the appropriate statistical testsgiven the research question and the number and typeof variables involved. For instance, if the researchersposed an association question they used anassociational statistical test. In contrast, if theresearchers asked a difference question they used adifference statistical test. Next, the researchers’conclusions are supported by significant statisticalresults. For instance, when analyzing the relationshipbetween speech and/or language impairments andlater literacy achievements all of the studies reportedp values of < .05. This further supports theresearchers’ conclusions because it reveals that therelationship between oral language delays andliteracy impairments is not likely due to chance.Lastly, the researchers’ interpretations of thestatistical tests were appropriate. For instance, all ofthe researchers discussed the issue that association

125

THE IMPACT OF ORAL LANGUAGE DELAYS ON LITERACY DEVELOPMENT

not does translate to causation. The researcherscommunicated that an oral language delay is only oneof many conditions or risk factors that shape anindividual’s future achievements. Therefore, giventhe appropriateness of the methodological practicesand the suitability of the statistical tests there isreason to accept the conclusion that an oral languagedelay is a risk factor for later literacy problems.

Prioritizing Speech and Language ServicesAlthough there is a consensus amongst the

researchers that there is a link between oral languageimpairments and literacy problems a debate stillexists regarding what specific component of thelanguage disorder or which subject-specific factorsare the best predictors of future literacy delays.

This debate is evident in the various researchfindings. For instance, while one study concludedthat subjects with non-developmental phonologicalprocesses were more likely to experience literacyproblems than subjects with developmentalphonological processes, another study argued thatlanguage impairments were a risk factor for literacyproblems, whereas speech impairments were not.

Therefore, even though the researchers agree thatin general, an oral language delay is a risk factor forfuture literacy problems, the use of varying cohortgroups makes it difficult to conclude which specificlanguage impairment is most in need of priorityspeech and language services.

Conclusions

A critical review of the available literature hasdemonstrated that there is strong evidence to suggestthat an oral language delay is a risk factor for futureliteracy impairments. However, there is notsufficient consensus and evidence in the research torecommend that children with a specific orallanguage delay should receive priority speech andlanguage services.

In order to determine who should receive prioritytreatment, future research should focus more closelyon several variables. First, researchers shouldquestion whether or not the nature of the languagedisorder (e.g., non-specific language impairment vs.specific language impairment) is a predictor of laterliteracy problems. Also, researchers should addresswhether or not the severity of the oral language delaypredicts who is more at risk for literacy problems.Lastly, researchers should consider whether or notthe environment of a child with an oral languagedelay affects his/her probability of developingliteracy deficits. By including these variables intotheir studies, researchers can determine whichchildren are most at risk of developing future literacy

delays and thus, should be prioritized for speech andlanguage services.

References

Bird, J., Bishop, D.V.M., & Freeman, N.H. (1995).Phonological awareness and literacydevelopment in children with expressivephonological impairments. Journal of Speechand Hearing Research, 38, 446-462.

Catts, H.W. (1993). The relationship between speech-language impairments and reading disabilities.Journal of Speech and Hearing Research, 36,948-958.

Felsenfeld, S., Broen, P.A., & McGue, M. (1994). A28-year follow-up of adults with a history ofmoderate phonological disorder: educational andoccupational results. Journal of Speech andHearing Research, 37, 1341-1353.

Leitao, S., & Fletcher, J. (2004). Literacy outcomesfor students with speech impairment: long-termfollow-up. International Journal of Language &Communication Disorders, 39, 245-256.

Paul, R. (2001). Language Disorders from Infancythrough Adolescents: Assessment & Intervention.Missouri, St. Louis: Mosby, Inc.

126

Copyright © 2005, Vosper, J.

The effectiveness of tinnitus retraining therapy

Vosper, J.M.Cl.Sc. (Aud) Candidate


This critical review examines the effectiveness of tinnitus retraining therapy (TRT) for patientswho suffer from chronic tinnitus. Study designs include: cross-sectional study, retrospective, casestudy, observational, prospective, and case control study. Overall, research concludes that TRT isan effective treatment; however, flaws in these studies’ methodologies make it difficult to drawany strong conclusions of its efficacy at this stage.

Introduction

Tinnitus is a perception of sound withoutexternal auditory stimulation. It is a symptom thatcan be related to a wide variety of physicaldisturbances. More than 360,000 Canadians havetinnitus in an annoying form and about 150,000 findthat these noises seriously impair the quality of theirlives (Tinnitus Association of Canada). Patients withdebilitating tinnitus experience great psychologicaldistress in that their tinnitus may disrupt their sleep,break their concentration, cause them to withdrawfrom social interactions and may lead to depression.

Therefore, careful review of current treatmentsand attempts to formulate new ones are valid andnecessary undertakings for audiologists. We must beknowledgeable and skilled with regards to the currenttreatment options available in order to help thesepatients improve their quality of life.

Due to the variety of possible causes of tinnitus,it has been difficult to find a single effectivetreatment. Some of the existing treatment optionsinclude: behavioural and dietary modifications,electrical stimulation, masking instruments, drugs,cognitive therapy, biofeedback, chiropracticmanipulation, and gingko biloba. There is currentlyno widely accepted treatment for tinnitus.

The purpose of this critical review is to evaluatethe effectiveness of tinnitus retraining therapy (TRT).TRT is one of the newest treatments and it has gainedinternational popularity and attention. Developed byDr. Jastreboff in the late 1980s, it is based on aneurophysiological and psychological model oftinnitus.

TRT aims to allow a patient to habituate to thetinnitus signal by modifying the neural connectionslinking the auditory with the limbic (emotions) andautonomic nervous systems. There is often nodifference in the psycho acoustic properties of thetinnitus sound “perceived by people who sufferbecause of it and those who are not bothered by it”(OHSU Tinnitus Clinic). Therefore, it is the reaction

to the tinnitus, not the tinnitus itself, that determinesif it becomes a debilitating problem.

The goal of TRT is to retrain the brain to respondto tinnitus as a neutral sound. This is accomplishedthrough intensive directive counseling sessions andthe use of masking.

The recommended duration of treatment isbetween 12 and 24 months. TRT is currently offeredin at least two centers in Ontario: the CanadianHearing Society’s Toronto Audiology Clinic and theTinnitus and Hyperacusis Assessment center locatedin Whitby. The fees for therapy are approximately$1000 to $3000. TRT is not covered by the OntarioHealth Insurance Plan (OHIP) and the noisegenerators are not covered under the AssistiveDevices Program (ADP) in Ontar io(www.canadiantinn.com). Once tinnitus habituationis achieved, there is no need for continuing thetreatment.

This thesis is being adopted and referenced bygrowing numbers of researchers and cliniciansaround the world. Lockwood and Salvi (1998) haveidentified specific neurophysiological mechanismsresponsible for tinnitus by measuring neural activityafter tinnitus was induced. They found activity in thelimbic system when tinnitus was present in subjects.TRT is directed at physiologically altering the bondbetween the limbic system and tinnitus. This is thefirst hard evidence that the theory may be valid.

Methods

The goals of the studies in this review were toquantify the impact of tinnitus, investigate the effectsof habituation, and address self-perceived disabilityin patients undergoing TRT.

The number of patients that were included in thestudies generally ranged from 32 to 1000 patients.Only one study explicitly stated the subject inclusionand exclusion factors. The studies usually includedpatients being treated at a specific center over aperiod of time. Convenience sampling was

127

THE EFFECTIVENESS OF TINNITUS RETRAINING THERAPY

employed, whereby the cases were self-selected bytheir presence in a particular program or clinic.

The designs used in these studies differed in theirmethodological rigour. These included: cross-sectional study, retrospective designs, case studies,prospective cohort studies, and observational study.Other studies, usually randomly assigned the subjectsto groups comparing full treatment TRT to treatmentsthat were composed of only one or two of thecomponents of treatment or used a waiting listcontrol group for treatment/ no treatmentcomparisons.

Prospective studies generally followed the samesteps: 1) medical evaluation to rule out retrocochleardisease, 2) case history, and 3) audiologicalevaluation. If receiving TRT then also 4) diagnosisand selection for the treatment category, 5) directivecounseling, 6) selection and fitting of hearing aids ornoise generators, and 7) follow-up counselingaccording to the individual needs of the patient andestablished timetable.

The subjects were either fit with no instrument,monaurally, binaural fitting of both wide band noisegenerators or hearing aids.

All subjects were evaluated at the beginning ofthe treatment, six months later and 12 months later asa minimum. The various measurements sought toassess the percentage of time spent awake duringwhich the subjects were aware of tinnitus, thepercentage of the time it caused distress orannoyance, the strength of the reaction and theimpact of tinnitus on various life factors.

Results

All of the results were presented as a proportionof people experiencing improvement after treatment.

TRT involves placing the patient into a treatmentcategory depending on the presence of hearing loss orhyperacusis in addition to chronic tinnitus. Moststudies did not give separate results for each categoryof treatment, and instead reported the overallpercentage of patients who showed improvement.One study examined the effects of habituation takingthe category of treatment into account. Bartnik et al.(2001) evaluated patients with tinnitus and subjectivehearing loss and compared them to the results ofpatients with tinnitus only after one year of treatment.Their results indicated improvement in about 70% ofpatients with tinnitus only and in about 90% ofpatients with tinnitus and subjective hearing loss afterone year of therapy, however this difference betweengroups was not significant. Their results supportedJastreboff’s previous claims that the type of devicesused for sound therapy has no significant impact onthe treatment outcome (Jastreboff, 1996).

Berry et al. (2001) used the Tinnitus HandicapInventory (THI) in their nonrandomized, prospectiveanalysis of patients undergoing TRT. THI scorescorrelated with subjective perception of overalltinnitus effect (p<.001). Following 6 months of TRT,the total, emotional, functional, and catastrophic THIscores significantly improved (p<.001). Although thesample size was small, every patient was followedup, and changes in the THI total score weresignificant. However, this study did not incorporatecontrol groups.

Four studies examined the effectiveness of TRTby dividing the patients into different treatmentgroups and/or control groups. One found that 64.5%of their patients improved significantly after theinitial group therapy, whereas the patients of thewaiting list control group showed no significantimprovement (Delb, 2002). McKinney was involvedin two studies: the first one found that theeffectiveness of the treatment varied from 64% to84%. In contrast, improvement in tinnitus relief wasobserved in only 6% of the non-treated group(Jastreboff & Jastreboff, 2004). The second studyshowed a 78% positive change in all variables in theTRT group and only 18.8% improvement in thecontrol group (Jastreboff & Jastreboff, 2004). Theselection procedures in the studies diminish thevalidity of these results. The patients in the treatmentgroups were referred to the clinic, whereas thecontrol group participants were recruited byadvertisements in a journal. A study done byJastreboff showed 83% significant improvement inpatients after TRT and an 18% improvement inpatients who received counseling only (Jastreboff,1996). However, these latter patients were notrandomly assigned to the counseling only group.They could not continue with the interventionpredominantly due to financial constraints. Theirlower response rate may be due to extraneous factorsassociated with lower socioeconomic status. The factthat Jastreboff is the developer of TRT may alsomake his results more prone to bias.

Case series of patients that attended specificclinics were reported. Sheldrake et al. (1999)reported that there was improvement in 96% of thepatients seen in one retrospective study. In another,observational study he reported that after treatmentwith TRT, 83.9% of their patients achieved asuccessful outcome on completing treatment.However, there are no details provided on the criteriato define ‘improvement’. At another location, 129patients received full treatment and 105 of thesepatients showed significant improvement (Wang, G,2004). Other clinics from around the world haveclaimed to experience success rates of 80-88%(Jastreboff & Jastreboff, 2004).

128


Caution must be used in interpreting theseresults. Aside from Berry et al. who used the THI,these studies lack a standardized, described outcomemeasurement. The two main methods used forobtaining results were the personal interview, whichis subject to interviewer and social desirability bias,and questionnaires. There was often littleinformation on the precise nature of the measurementprocedure used to obtain awareness indices. Theexact questions asked and the rating scales used werenot usually included or described. These articles alsolack the inclusion of raw data and statistical analyses.

The criterion for success also differs amongstudies. Successful treatment is usually defined as aspecific percentage improvement in annoyance orawareness, plus an improvement of one life factor.These studies used 20%, 30% or 40% improvementcriterion. However, there is no indication of howthese percentages were calculated from the outcomemeasures used. The questionnaire developed byJastreboff, for example, is composed of a variety ofquestions whose answers are not all numerical andthe calculation of a percentage improvement from theresponses was not described. Without properdefinition, ‘improvement’ may mean anything from aslight reduction in tinnitus-related distress to theelimination of tinnitus altogether.

In all studies, the results were collected atmultiple times, which is appropriate because TRTresults in progressive improvements over time. Thegreatest improvement occurs after 3-6 months(Jastreboff & Jastreboff, 2004). It has been arguedthat patients who are recorded as havingunsuccessfully improved do not represent failure. Itmay only mean that they did not achieve the criterionby the time stated. Some patients may have receivedbenefit, but they may take longer to achievehabituation.

Due to the lack of information regarding theoutcome measures used in the studies, it is difficult toascertain the validity and reliability of the results.Aside from the THI, the questionnaires have notundergone psychometric testing. It can also not bedetermined whether appropriate methodological andstatistical techniques were applied. They wereadequately described in only two studies (Bartnik, etal, 2001;Berry, et al, 2002).

Recommendations

Results from all of the studies included in thisreview conclude that TRT is shown to be an effectivetreatment. The success rates usually cluster around80% of the patients showing improvement andreduction of annoyance to their tinnitus. However,flaws in their methodologies make it difficult to draw

any strong conclusions about the efficacy of TRT atthis stage (Wilson et al, 1998). TRT cannot bedemonstrated to be superior to other treatments dueto the lack of comparative studies.

At the same time, there is no evidence in thisliterature to the contrary. That is, none of the studiesreported zero, low or even moderate success rates.

Following this review, the recommendation is toprovide information regarding TRT to chronictinnitus sufferers as one option, among others. Thisinvestigation has shown that TRT has helped somepatients and it has the potential to help others in thefuture. However, the literature does not satisfactorilydescribe the criteria for patient selection so thestudies do not suggest a patient subgroup most likelyto respond to TRT.

As clinicians, we must demand evidence of itsefficacy through strong studies presented in peerreview journals. An ideal research design would be aprospective control group design that randomlyassigns patients to different treatment groups andincludes a waiting list control group. There must bepublished protocols and structured assessmentmethods to ensure consistency with TRTimplementation and evaluation across studies. Theuse of the Tinnitus Handicap Inventory (THI) is alsohighly recommended. It is desirable for its ease ofadministration, incorporation of functional as well asemotional constructs, good construct validity, andstrong internal consistency and test-retest reliabilities.It can also provide a comparison point against which1) samples can be compared for initial severity and 2)treatments can be judged in terms of the size of theireffects (Berry et al, p 1153).

Until research that is more rigorous has beenundertaken, we must be certain to tell our patientsthat TRT is promising, but currently controversialand investigative.

If the patient has already tried numerous otherapproaches, is experiencing a reduced quality of lifebecause of their tinnitus, and they are willing tospend the money then I feel that it is alright toencourage them to try this treatment. For one, thisreview did not find any literature that suggests thatthis treatment creates any harm for the patient nor hasany negative side effects. Secondly, there iscurrently no widely accepted treatment for tinnitus.If they are interested, the clinician should recommendattending a general information session at one ofthese centers before they commit to the therapy todecide if they want to pursue TRT further. We mustaid them in finding a proper person who is qualifiedto carry out this treatment. It has been suggested thatsome people claim to offer TRT without possessingsufficient knowledge of the method (Kroener-Herwiget al, 2000).

129


The information that is beginning to emergeabout this treatment looks promising. Moreover, theconnections found between the limbic system andtinnitus is an extremely interesting development,especially in regards to this neurophysiologicaltheory. More research and clinical studies are inprogress in a number of centers to validate theeffectiveness of TRT in a formal manner (Jastreboff,2001). In conclusion, this review agrees with thestatement that while there “are no grounds fordiscrediting TRT, neither is there reason to claim itssuperior efficacy” (Kroener-Herwig et al, p 77,2000).

References

Bartnik, G, et al. (2001). Effects of tinnitus retrainingtherapy (TRT) for patients with tinnitus andsubjective hearing loss versus tinnitus only.Scandinavian Audiology, 30S(52), 206-208.

Berry, JA, et al. (2002). Patient-based Outcomes inPatients with Primary Tinnitus UndergoingTinnitus Retraining Therapy. Archives ofOtolaryngology. Head & Neck Surgery, 128,1153-1157.

Canadian Tinnitus and Hyperacusis Centre.www.canadiantinn.com

Delb, W, et al. (2002). Evaluation of the tinnitusretraining therapy as combined with a cognitivebehavioral group therapy. HNO, 50, 997-1004.

Hazell JWP. The TRT method in Practice. SixthInternational Tinnitus Seminar 1999.

Jastreboff, P.J., Hazell, J.W.P., Graham, R.L. (1994).Neurophysiological model of tinnitus:Dependence of the minimal masking level ontreatment outcome. Hearing Research, 80, 216-232.

Jastreboff, P.J., Gray, W.C., Gold, S.L. (1996).Neurophysiological approach to tinnitus patients.American Journal of Otology, 17, 236-240.

Jastreboff, PJ and Jastreboff, MM. (2004). TinnitusRetraining Therapy: An Update.

Jastreboff, PJ and Jastreboff, MM. (2001). TinnitusRetraining Therapy. Seminars in Hearing,22(1).

Jastreboff, PJ and Jastreboff, MM. (2003). TinnitusRetraining Therapy for patients with tinnitus anddecreased sound tolerance. OtolaryngologyClinics of North America, 36, 321-336.

Jastreboff PJ, Jastreboff MM. (2000). TinnitusRetraining Therapy (TRT) as a method fortreatment of tinnitus and hyperacusis patients.Journal of the American Academy of Audiology,11, 162-177.

Keate, B. (2004). Electrical Stimulation forSuppression of Tinnitus. Retrieved October 3,2004 from www.tinnitusformula.com

Kroener-Herwig, B et al. (2000). Retraining therapyfor chronic tinnitus: a critical analysis of itsstatus. Scandinavian Audiology, 29, 67-78.

Lockwood, A.H., et al. (1998). The functionalneuroanatomy of tinnitus: Evidence for limbicsystem links and neural plasticity. Neurology, 1.

OHSU Tinnitus Clinic.http://www.ohsu.edu/ohrc/tinnitusclinic/compTreatments.html

Sheldrake JB, Hazell JWP, Graham RL. (1999).Results of tinnitus retraining therapy.Proceedings of the Sixth International TinnitusSeminar, Cambridge, UK, J. Hazell, ed, THC,London, pp. 292-296.

Skarzynski, H, et al. (2000). Organization of TinnitusManagement in Poland. Acta Otolaryngology,120, 225-226.

Soundidears, INC. Tinnitus Retraining Therapy(TRT). www.soundidears.com

Tinnitus Association of Canada website:www.kadis.com/ta/tinnitus.htm

Wang, G. (2004) Tinnitus Retraining Therapy.Health Technology Assessment, Department ofLabor and Industries.

Wilson, PH, et al. (1998). A critical analysis ofdirective counseling as a component of tinnitusretraining therapy. British Journal of Audiology.32, 273-286.

130

Copyright © 2005, Washington, K., Warr-Leeper, G., Salazer, R.G., Gain, K., & Koyanagi, K.

Improving the oral language foundation for reading:Phonological awareness and narrative skills

Washington, K., M.Sc.1, Warr-Leeper, G., Ph.D.2, Salazer, R.G., M.S.3,Gain, K., M.Sc.3, & Koyanagi, K., B.Sc.4

1Doctoral Program in Rehabilitation Sciences, The University of Western Ontario, London, Ontario2School of Communication Sciences and Disorders, The University of Western Ontario, London, Ontario3Speech and Language Services, Thames Valley District School Board, London, Ontario4Research Department, Thames Valley District School Board, London, Ontario

The phonological awareness (PA) skills of a large sample of senior kindergarten students wereexamined prior to and following a broad range of programming. Positive outcomes were foundwith varied patterns of change for different types PA skills. Continued work to include other orallanguage skills foundational to reading, namely narrative skills, is underway. Story retelling (SR)as a tool for assessing and guiding programming of narrative skills is currently being explored.

131

Copyright © 2005, Webster, W.G.

Voluntary swallowing in people who stutter

Webster, W.G.1

School of Communication Sciences and DisordersThe University of Western Ontario, London, Ontario

People who stutter not only have difficulty with the organization and initiation of speechmovements but also of sequential finger movements and bilaterally coordinated hand movements.It is hypothesized that this reflects disfunction of the the supplementary motor area (SMA). Thecurrent study was designed to assess whether similar behavioural anomalies are evident withvoluntary swallowing, a motor response that is thought to involve the SMA. If there are anomaliesin swallowing in adults who stutter, it opens the possibility of using voluntary swallowing to trackchanges in SMA function in children that may accompany recovery from stuttering.

Adults who stutter and age and sex matched control participants were compared on three tasksrequiring voluntary swallowing: 1) choice response task in which subjects had to either swallow ortouch the tongue to the upper lip or press a button with the thumb when one or another stimuluscue was presented; 2) a go-no go task in which subjects had to swallow when one cue waspresented but do nothing when either of the two other cues used in condition 1 was presented; and3) a repetitive swallowing task in which subjects were asked to swallow repeatedly for 30 secondsafter the presentation of the cue. Swallowing was recorded using a pressure transducer placed nextto the larynx and respiration was monitored with a respiratory belt placed around the chest.Dependent measures of swallowing included swallow onset time, duration of swallows, durationof respiration interruption during swallowing and, in the case of condition 3, number of swallowsperformed in the 30 second period. Although there were some minor differences between thegroups, our conclusion is that in contrast to the case of performance of oral movements associatedwith speech and the performance of sequential finger movements, people who stutter show noanomalies in swallowing. This may reflect the highly automatic nature of swallowing onceinitiated, and/or that the organization and initiation of this response may involve different brainmechanisms than those associated with speech and manual responses. Either way, it does not seemas if this will be a useful approach for the study of brain organization in young children.

132

practice evidence - uwo.ca · impact of otitis media on later developing language skills in...

Documents