Short-term effect of short, intensive speech therapy on articulation and resonance in Ugandan patients with cleft (lip and) palate

Management of Speech and Hearing in Low-Income and Middle-Income Countries: Current Conditions, Problems, Future Directions

Management of speech and hearing issues in low-income and middle-income countries (LMICs) has been challenging, considering the population size and availability of resources. There is a need to investigate the depth of these challenges and explore the efficacy of strategies to overcome them. This review aimed to delineate the speech and hearing issues in individuals with cleft lip and palate and how they have been managed in the context of LMICs. Keywords were developed based on the objectives of the study to search for literature published during the period 2010 to 2023. Articles from PubMed, Google Scholar, Science Direct, and ProQuest databases were retrieved using appropriate keyword searches. The titles and abstracts were screened to delete the unsuitable articles. Relevant gray literature and hand-searched articles published were also included. The findings are summarized under the following heads in the context of LMICs: incidence and severity of speech and hearing issues, challenges, and barriers in providing speech and hearing services, methods of developing manpower and training, methods of assessing speech and hearing outcomes, service delivery models employed, and the recent advances relating to management of speech and hearing. A wide range of topics revolving around managing speech and hearing issues in individuals with cleft lip and palate has been researched in the context of LMICs. Scattered and fragmented solutions have been provided to overcome the varied challenges in LMICs. The gaps in the literature and the future directions for research have been identified.

Speech and Resonance Disorders in Children With Cleft Palate: Diagnostic Evaluation and Current Speech Therapy Modalities

This article will provide an overview of how speech and resonance can be impacted in children with cleft palate. The authors will outline evidence-based assessment and treatment approaches commonly used for children with cleft palate and provide information on current initiatives to provide speech therapy. The methods discussed will be the use of telehealth to provide access to speech therapy for patients in areas without speech-language pathologists and the use of speech therapy camps to offer intensive, limited-duration speech therapy for groups of children due to the lack of trained providers in certain geographical regions.

Impact of an International Training on Interventionists' Expertise in Cleft Palate Speech: Results From Oaxaca, Mexico

PURPOSE

International cleft lip and palate surgical charities recognize that speech therapy is essential for successful care of individuals after palate repair. The challenge is how to ensure that cleft speech interventionists (i.e., speech-language pathologists and other speech therapy providers) provide quality care. This exploratory study investigated effects of a two-stage cleft training in Oaxaca, Mexico, aimed at preparing speech interventionists to provide research-based services to individuals born with cleft palate. Changes in the interventionists' content knowledge and clinical skills were examined.

METHOD

Twenty-three cleft speech interventionists from Mexico, Guatemala, and Nicaragua participated in a hybrid two-stage training, completing an online Spanish cleft speech course and a 5-day in-person training in Oaxaca. In-person training included a didactic component and supervised clinical practice with 14 individuals with repaired cleft palates. Testing of interventionists' content knowledge and clinical skills via questionnaires occurred before the online course (Test 1), immediately before in-person training (Test 2), and immediately after in-person training (Test 3). Qualitative data on experience/practice were also collected.

RESULTS

Significant increases in interventionists' overall content knowledge and clinical skills were found posttraining. Knowledge and clinical skills increased significantly between Tests 1 and 2. Clinical skills, but not knowledge, showed further significant increases between Tests 2 and 3. Posttraining, interventionists demonstrated greater expertise in research-based treatment, and fewer reported they would use nonspeech oral motor exercises (NSOME).

CONCLUSIONS

Findings provide preliminary support for such two-stage international trainings in preparing local speech interventionists to deliver high-quality speech services to individuals born with cleft palate. While content knowledge appears to be acquired primarily from the online course, the two-stage training incorporating in-person supervised practice working with individuals born with cleft palate may best enhance continued clinical skill development, including replacement of NSOME with evidence-based speech treatment. Such trainings contribute to building capacity for sustainable quality services for this population in underresourced regions.

Speech Task Force and Quality of Life after Surgery in Children with Cleft Lip and Palate: Limitation of Professionals

Background  Shortage of speech and language therapists results in lack of speech services. The aims of this study were to find the effectiveness of a combination speech therapy model at Level IV: General speech and language pathologist (GSLP) and Level V: Specific speech and language pathologist (SSLP) in reduction of the number of articulation errors and promotion the quality of life (QoL) for children with cleft palate with or without cleft lip (CP ± L). Methods  Fifteen children with CP ± L, aged 4 years 1 month to 10 years 9 months (median = 76 months; minimum:maximum = 49:129 months) were enrolled in this study. Pre- and post-assessment included oral peripheral examination; articulation tests via Articulation Screening Test, Thai Universal Parameters of Speech Outcomes for People with Cleft Palate, Hearing Evaluation, The World Health Organization Quality of Life Brief_Thai (WHOQOL-BRIEF-THAI) version questionnaire for QoL were performed. Speech therapy included a 3-day intensive speech camp by SSLP, five 30-minute speech therapy sessions by a GSLP, and five 1-day follow-up speech camps by SSLP that provided four 45-minute speech therapy sessions for each child. Results  Post-articulation revealed statistically significant reduction of the numbers of articulation errors at word, sentence, and screening levels (median difference [MD] = 3, 95% confidence interval [CI] = 2-5; MD = 6, 95% CI = 4.5-8; MD = 2.25, 95% CI = 1.5-3, respectively) and improvement of QoL. Conclusion  A speech task force consisting of a combination of Level IV: GSLP and Level V: SSLP could significantly reduce the number of articulation errors and promote QoL.

Feasibility of using ultrasound visual biofeedback to treat persistent speech sound disorders in children with cleft palate- a case series

The current study aimed to assess the effectiveness of incorporating ultrasound visual biofeedback (UVB) into a treatment programme addressing persistent speech sound disorders linked to cleft palate in children who have been unresponsive to traditional therapy approaches. Materials and Methods. A single-subject multiple baseline experiment was conducted with five children aged 6:5-13:5 over a period of 16 therapy sessions. Treatment focused on providing cues from real-time ultrasound images to assist children in modifying their tongue movements. Probe data were collected before, mid, and post-treatment to assess target consonant accuracy for 50 untreated words. The results of the statistical analysis suggested participants showed a significant increase in percent target consonant accuracy as a result of intervention using UVB. Although most of the participants exhibited progress in generalising learned phonemes to untreated words, some did not show improvement in gaining generalisation from treated phonemic contexts to those untreated ones. When traditional methods fail to yield significant progress, incorporating ultrasound biofeedback into the treatment programme emerges as a viable option to enhance sound accuracy in children with persistent speech sound disorders resulting from cleft palate.

The retrospective acceptability of high intensity versus low intensity speech intervention in children with a cleft palate: A qualitative study from the parents' point of view using the Theoretical Framework of Acceptability

BACKGROUND

Increasing attention is paid to the effectiveness of high-intensity speech intervention in children with a cleft (lip and) palate (CP±L). It is, however, unknown if high-intensity intervention is acceptable to the intervention recipients. Parents have an integral role in supporting their children with intervention highlighting the importance of intervention acceptability to parents.

AIMS

To compare the retrospective acceptability of high-intensity speech intervention (10 1-hr speech therapy sessions divided over 2 weeks) with the retrospective acceptability of low-intensity speech intervention (10 1-hr speech therapy sessions divided over 10 weeks) for children with a CP±L from the parents' point of view.

METHODS & PROCEDURES

Twelve parents of 12 children, aged 6-0 years who received high-intensity speech intervention (n = 6) or low-intensity speech intervention (n = 6), were invited to participate in this study. Seven parents (n = 3 in the high-intensity group and n = 4 in the low-intensity group) agreed to participate (total response rate: 7/12, 58.33%). A qualitative study design using semi-structured interviews was applied. To investigate the retrospective acceptability of the two intervention intensities, deductive coding according to the Theoretical Framework of Acceptability (TFA) was used.

OUTCOMES & RESULTS

With regard to the TFA construct 'affective attitude', results demonstrated that parents had positive feelings about the provided speech intervention regardless of the intensity. Parents of children who received high-intensity speech intervention reported two specific benefits related to the high intervention intensity: (1) it improved their relationship with the speech-language pathologist and (2) it improved their child's ability to make self-corrections in his/her speech. Even though both high-intensive and low-intensity speech intervention were considered burdensome (TFA construct 'burden'), parents were less likely to drop out of high-intensity intervention because the total intervention period was kept short.

CONCLUSIONS & IMPLICATIONS

In conclusion, high-intensity speech intervention seemed acceptable to parents. More positive codes were identified for some of the TFA constructs in the high-intensity intervention group than in the low-intensity intervention group. Considering that some parents doubted their self-efficacy to participate in high-intensity speech intervention, speech-language pathologists need to counsel them so that they can adhere to the high intervention intensity. Future studies should investigate whether high-intensity speech intervention is also acceptable to the children who receive the intervention and to the speech-language pathologists who deliver the intervention.

WHAT THIS PAPER ADDS

What is already known on this subject Increasing attention is paid to the effectiveness of high-intensity speech intervention in children with a cleft (lip and) palate (CP±L). Different quantitative studies have shown positive speech outcomes after high-intensity cleft speech intervention. Despite this increasing attention to high-intensity speech intervention, it is unknown whether high-intensity intervention is also acceptable to the intervention recipients. This study compared the retrospective acceptability of high-intensity speech intervention (10 1-hour speech therapy sessions divided over 2 weeks) with the retrospective acceptability of low-intensity speech intervention (10 1-hour speech therapy sessions divided over 10 weeks) in children with a CP±L from the parents' point of view. What this paper adds to existing knowledge More positive codes were identified for some of the TFA constructs in the high-intensity intervention group than in the low-intensity intervention group. Nevertheless, some parents doubted their self-efficacy to participate in high-intensity speech intervention. What are the potential or actual clinical implications of this work? The findings of this study forces us to reconsider the traditional cleft speech intervention delivery models which usually consist of low-intensity intervention. Speech-language pathologists need to counsel parents and so that they can adhere to the high intervention intensity.

Speech Intervention for Children With Cleft Palate Using Principles of Motor Learning

PURPOSE

This is a pilot study to apply an articulatory kinematic speech intervention that uses the principles of motor learning (PML) to improve speech and resonance outcomes for children with cleft palate. It is hypothesized that (a) treatment that applies select PML during practice will improve production of treated phonemes, representing both active and inconsistent passive errors, at word level in children with cleft palate; (b) effects of practice on phonemes with active or inconsistent passive errors will generalize to untreated exemplars of treated phonemes; and (c) learning will be retained for at least 1-month posttreatment.

METHOD

A multiple-baseline design across participants combined with a crossover single-case experimental model was used. Participants attended two 8-week blocks of twice-weekly face-to-face speech therapy (40-50 min/treatment) to treat active and inconsistent passive cleft speech errors using articulatory kinematic speech intervention that applied PML. The participants were four children with cleft-type speech errors. The primary dependent variable measured was percentage of words correct across treatment items, generalization items, and control items. Perceptual accuracy of target words was scored. Effect sizes were calculated to quantify the magnitude of treatment effect.

RESULTS

For three children with active and inconsistent passive cleft speech errors and one child with active cleft speech errors and developmental phonological speech errors, this approach resulted in improvements to their treated items and generalization to their untreated items. Inconsistent passive cleft speech errors were particularly responsive to the treatment in the three children who presented with these errors.

CONCLUSION

This Phase I study has shown that articulatory kinematic speech intervention that applies the PML is effective in improving the speech outcomes for children with cleft palate and that there is validity in pursuing further research into this approach.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21644831.

Influence of an Intensive Speech Therapy Program on the Speech of Individuals with Cleft Lip and Palate

Introduction  Compensatory articulations are speech disorders due to the attempt of the individual with cleft palate/velopharyngeal dysfunction to generate intraoral pressure to produce high-pressure consonants. Speech therapy is the indicated intervention for their correction, and an intensive speech therapy meets the facilitating conditions for the correction of glottal stop articulation, which is the most common compensatory articulation. Objective  To investigate the influence of an intensive speech therapy program (ISTP) to correct glottal stop articulation in the speech of individuals with cleft palate. Methods  Speech recordings of 37 operated cleft palate participants of both genders (mean age = 19 years old) were rated by 3 experienced speech/language pathologists. Their task was to rate the presence and absence of glottal stops in the 6 Brazilian Portuguese occlusive consonants (p, b, t, d, k, g) distributed within several places in 6 sentences. Results  Out of the 325 pretherapy target consonants rated with glottal stop, 197 (61%) remained with this error, and 128 (39%) no longer presented it. The comparison of the pre- and posttherapy results showed: a) a statical significance for the p1, p2, p3, p4, t1, k1, k2 and d6 consonants (McNemar test; p  < 0.05); b) a statistical significance for the p consonant in relation to the k, b, d, g consonants and for the t consonant in relation to the b, d, and g consonants (chi-squared test; p  < 0.05) in the comparison of the proportion improvement among the 6 occlusive consonants. Conclusion  The ISTP influenced the correction of glottal stops in the speech of individuals with cleft palate.

On the Benefits of Speech-Language Therapy for Individuals Born With Cleft Palate: A Systematic Review and Meta-Analysis of Individual Participant Data

PURPOSE

Cleft lip and/or palate (CLP) is a common birth defect, and after reconstructive surgery, about 50% of children at 5 years of age have speech deviations and are referred to speech-language therapy (SLT). The peer-reviewed evidence for the benefit of SLT has been uncertain. Our objective was to systematically review and meta-analytically summarize the benefit of SLT for individuals born with CLP.

METHOD

A systematic search was conducted (last search on February 19, 2021) on studies evaluating SLT with pre and post measures on speech production, language ability, intelligibility, and/or patient-reported outcomes. We sought individual participant data (IPD) and evaluated on an individual level if the outcome measure had improved to a clinically relevant degree during SLT and if the outcome measure was on a level with peers or not after SLT. Meta-analyses and meta-regressions were applied to synthesize IPD across studies.

RESULTS

Thirty-four eligible studies were found. Nineteen studies provided IPD (n = 343) for the main analysis on speech production. The synthesized information suggests that, during SLT, speech production improved to a clinically relevant degree for many individuals (95% CI [61%, 87%]) and that speech production was on a level with peers for some individuals after SLT (95% CI [10%, 34%]).

CONCLUSIONS

The main strength of this meta-analysis is that we evaluated on an individual level pre- and post-intervention data based on considerations of clinical relevance. This approach allowed us to conclude that many individuals benefit from SLT and that further work on evaluating SLT in this patient group is meaningful. Supplemental Material https://doi.org/10.23641/asha.17700992.

Parents' perceptions on speech therapy delivery models in children with a cleft palate: A mixed methods study

PURPOSE

This study investigated parents' perceptions on two different speech therapy delivery models in children with a CP ± L, namely an innovative high intensity speech intervention (i.e. HISI: 10 1-h sessions divided over 2 weeks) and a low intensity speech intervention (i.e. LISI: 10 1-h sessions divided over 10 weeks).

METHOD

Twelve parents of 12 children who received HISI (n = 6) or LISI (n = 6) were contacted with the request to participate to this study to review their opinion on the received therapy. Participation included the completion of a questionnaire containing items related to satisfaction, speech progress, intervention intensity and frequency, transfer, and need for further speech therapy. Additionally, semi-structured interviews were carried out. The interviews were analyzed using an inductive thematic approach.

RESULTS

There were no significant differences between the two groups in satisfaction with the "general speech therapy, "duration of one speech therapy session", "total intervention duration" and "degree of improvement of speech intelligibility". Following HISI, parents perceived more improvement in terms of spontaneous speech and better resolution of the speech disorders. The interviews revealed 3 themes of importance to the parents: (1) treatment-related expectations, (2) treatment-related burden, and (3) patient-therapist relationship. Parents in the HISI group reported two concerns: (1) the lack of variation when receiving daily intervention, and (2) the emotional burden when the child is confronted with his/her speech disorder on a daily basis.

CONCLUSIONS

Parents were equally satisfied with the provided intervention. Parents in the HISI group perceived more speech progress following the intervention compared to parents in the LISI group. The intensive contact with the speech pathologist enhanced the patient-therapist relationship. To support a cultural shift away from low intensity therapy delivery models, it will be important to counsel and inform parents of the benefits of HISI and to counterbalance concerns.

Is High-Intensity Speech Intervention Better? A Comparison of High-Intensity Intervention Versus Low-Intensity Intervention in Children With a Cleft Palate

Purpose The purpose of this study was to compare the effect of speech intervention provided with a low intensity with speech intervention provided with a high intensity on the speech and health-related quality of life (HRQoL) in Dutch-speaking children with a cleft palate with or without a cleft lip (CP ± L) between 4 and 12 years. Method A longitudinal, prospective, randomized controlled trial with a multiple baseline design was used. Twelve children with a CP ± L (M _age = 8.0 years, SD = 1.54) were divided into two groups using block randomization stratified by age and gender: One group received low-intensity speech intervention (LISI; n = 6) and one group received high-intensity speech intervention (HISI; n = 6). Children in the LISI group received intervention with a session duration of 1 hr, a dose frequency of 1 session per week, and a total intervention duration of 10 weeks. Children in the HISI group received intervention with a session duration of 1 hr, a dose frequency of 5 sessions per week, and a total intervention duration of 2 weeks. The cumulative intervention intensity was kept constant. Both groups received identical therapy programs provided by the same experienced speech therapist. Perceptual speech assessments were performed on baseline and posttreatment data points. Changes in HRQoL were assessed using the Velopharyngeal Insufficiency Effects on Life Outcomes (VELO) questionnaire. Both groups were compared over time using (generalized) linear mixed models. Results No significant Time × Group interactions were observed for the percentage of correctly produced consonants at the word and sentence levels, indicating no differences in evolution over time among the two groups. The variables speech understandability, speech acceptability, and the total VELO scores significantly improved following HISI, but not following LISI. Conclusions Children in the HISI group made equal and, for some variables, even superior progress in only 2 weeks of therapy compared to children in the LISI group who received 10 weeks of therapy. HISI is a promising strategy to improve speech outcomes and HRQoL in a shorter time period.

Unravelling 'low-resource settings': a systematic scoping review with qualitative content analysis

INTRODUCTION

The effects of healthcare-related inequalities are most evident in low-resource settings. Such settings are often not explicitly defined, and umbrella terms which are easier to operationalise, such as 'low-to-middle-income countries' or 'developing countries', are often used. Without a deeper understanding of context, such proxies are pregnant with assumptions, insinuate homogeneity that is unsupported and hamper knowledge translation between settings.

METHODS

A systematic scoping review was undertaken to start unravelling the term 'low-resource setting'. PubMed, Africa-Wide, Web of Science and Scopus were searched (24 June 2019), dating back ≤5 years, using terms related to 'low-resource setting' and 'rehabilitation'. Rehabilitation was chosen as a methodological vehicle due to its holistic nature (eg, multidisciplinary, relevance across burden of disease, and throughout continuum of care) and expertise within the research team. Qualitative content analysis through an inductive approach was used.

RESULTS

A total of 410 codes were derived from 48 unique articles within the field of rehabilitation, grouped into 63 content categories, and identified nine major themes relating to the term 'low-resource setting'. Themes that emerged relate to (1) financial pressure, (2) suboptimal healthcare service delivery, (3) underdeveloped infrastructure, (4) paucity of knowledge, (5) research challenges and considerations, (6) restricted social resources, (7) geographical and environmental factors, (8) human resource limitations and (9) the influence of beliefs and practices.

CONCLUSION

The emerging themes may assist with (1) the groundwork needed to unravel 'low-resource settings' in health-related research, (2) moving away from assumptive umbrella terms like 'low-to-middle-income countries' or 'low/middle-income countries' and (3) promoting effective knowledge transfer between settings.

Perceptual Speech Outcomes After Early Primary Palatal Repair in Ugandan Patients With Cleft Palate

OBJECTIVE

To provide speech outcomes of English-speaking Ugandan patients with a cleft palate with or without cleft lip (CP±L).

DESIGN

Prospective case-control study.

SETTING

Referral hospital for patients with cleft lip and palate in Uganda.

PARTICIPANTS

Twenty-four English-speaking Ugandan children with a CP±L (15 boys, 9 girls, mean 8.4 years) who received palatal closure prior to 6 months of age and an age- and gender-matched control group of Ugandan children without cleft palate.

INTERVENTIONS

Comparison of speech outcomes of the patient and control group.

MAIN OUTCOME MEASURES

Perceptual speech outcomes including articulation, resonance, speech understandability and acceptability, and velopharyngeal composite score (VPC-sum). Information regarding speech therapy, fistula rate, and secondary surgery.

RESULTS

Normal speech understandability was observed in 42% of the patients, and 38% were judged with normal speech acceptability. Only 16% showed compensatory articulation. Acceptable resonance was found in 71%, and 75% of the patients were judged perceptually to present with competent velopharyngeal function based on the VPC-sum. Additional speech intervention was recommended in 25% of the patients. Statistically significant differences for all these variables were still observed with the control children (P < .05).

CONCLUSIONS

Overall, acceptable speech outcomes were found after early primary palatal closure. Comparable or even better results were found in comparison with international benchmarks, especially regarding the presence of compensatory articulation. Whether this approach is transferable to Western countries is the subject for further research.

Reliability results of perceptual ratings of resonance, nasal airflow and speech acceptability in patients with cleft palate by Ugandan speech-language pathologists following a two-day workshop

INTRODUCTION

To meet the scarcity of training and/or educational initiatives in Uganda regarding state-of-the-art speech diagnosis and treatment in patients with cleft palate, a workshop was organized for all interested speech-language pathologists and health care workers.

OBJECTIVE

To evaluate and compare the inter- and intra-rater reliability of the perceptual evaluation of hypernasality, hyponasality, nasal emission, nasal turbulence and speech acceptability before and after a two-day workshop in Ugandan speech-language pathologists.

METHODS

On the first day, perceptual speech evaluation was discussed and practiced. Perceptual exercises included individual ratings of a specific speech variable followed by a group discussion and consensus listening exercises in listener pairs. The second day focused on speech treatment. Ten Ugandan speech-language pathologists rated speech samples of Ugandan patients with a CP ± L before and immediately following the two-day workshop. Inter- and intra-rater reliability of the perceptual ratings of hypernasality, hyponasality, nasal emission, nasal turbulence and speech acceptability were determined by means of the absolute percentage of agreement. The Wilcoxon signed-rank test was used to compare results at both time points.

RESULTS

Overall inter- and intra-rater reliability improved when observing the absolute percentage agreement. However, median agreement results only showed enhanced reliability for hypernasality, hyponasality and nasal turbulence whereas (limited) deteriorated reliability was observed for nasal emission and speech acceptability. Regarding inter-rater reliability only the median percentage agreement for hyponasality exceeded 50% (median: 56.3%). Overall, better results were found for intra-rater reliability, with only weak results for speech acceptability.

DISCUSSION AND CONCLUSION

Training positively affected reliability results. Nonetheless, this improvement was not achieved for each speech variable and reliability improvements were modest. Findings indicate the need for continued training and the search for the most effective training paradigm and feedback techniques, whilst taking into account clinical relevance and practical considerations.

Intensive speech therapy in Ugandan patients with cleft (lip and) palate: a pilot-study assessing long-term effectiveness

BACKGROUND/AIMS

In resource-limited countries, traditional models for speech therapy delivery are not adequate to reach all patients in need. In those countries, intensive speech therapy might be a solution. Preliminary results of previous research demonstrated that intensive speech therapy can be effective in the short term for patients living in countries with limited access to speech therapy. Questions might arise whether or not intensive treatment results in long-term benefits for these patients. Hence, the present study investigated long-term effectiveness of intensive speech therapy provided to Ugandan patients born with a cleft palate with or without cleft lip (CP ± L) in terms of different speech characteristics.

METHODS

Five Ugandan patients with CP ± L, who received intensive speech therapy in the past, were contacted to participate in this follow-up study. All patients agreed to participate. Perceptual and instrumental speech evaluations were performed identically to the assessments immediately before and after speech therapy, to allow for comparison. Additionally, the Cleft Evaluation Profile, investigating self-perceived satisfaction with cleft-related features was included to compare satisfaction before and after speech therapy.

RESULTS

Long-term improvement in percentage correct consonants was seen in four patients. Furthermore, after speech therapy, decreased presence of resonance disorders was observed in two of the included patients. Before speech therapy, all participants were dissatisfied with speech. Interestingly, after intensive speech therapy, satisfaction with speech was seen in every patient and this satisfaction remained in the long term.

CONCLUSION

In summary, speech improvements after speech therapy varied among the five patients. Nevertheless, present study provided encouraging results to further investigate effectiveness of intensive speech therapy in patients with CP ± L.