Optimal intervention intensity in speech-language pathology: discoveries, challenges, and unchartered territories

Aligned or misaligned: Are public funding models for speech-language pathology reflecting recommended evidence? An exploratory survey of Australian speech-language pathologists

Government subsidised funding arrangements serve as an essential medium for families to access private speech-language pathology (SLP) services in Australia. This study aimed to investigate whether, from a provider perspective, contemporary public funding models (PFMs) align with best-available scientific evidence for management of children and young persons with swallowing and communication disorders within Australian private-practice settings. This exploratory study was distributed to paediatric speech-language pathologists throughout Australia via an online survey. A total of 121 valid surveys were completed by Australian speech-language pathologists with divergent career experiences. In comparing three familiar PFMs using mixed effects logistic regression models to estimate odds ratios, results indicated that perceived congruence with recommended scientific evidence for SLP management varied across PFMs: the odds of failing to align with scientific evidence was 4.92 times higher for Medicare's Chronic Disease Management Plan (MBS_CDMP) than for the National Disability Insurance Scheme; and 7.40 times higher in comparison to Medicare's Helping Children with Autism initiative. This study is the first to report on (in)congruence between PFMs that provide access to independent Australian SLP services for children and young persons and best available scientific evidence to inform clinical practice. Participants identified that: (a) four out of seven contemporary PFMs were unfamiliar to speech-language pathologists; and (b) MBS_CDMP initiative failed to align with the evidence-base for best scientific SLP management.

Intensive and comprehensive aphasia therapy-a survey of the definitions, practices and views of speech and language therapists in the United Kingdom

BACKGROUND

Research evidence suggests aphasia therapy must be delivered at high intensity to effect change. Comprehensive therapy, addressing all domains of the International Classification of Functioning, Disability and Health, is also called for by people with aphasia and their families. However, aphasia therapy is rarely intense or comprehensive. Intensive Comprehensive Aphasia Programmes (ICAPs) were designed to address this challenge, but such programmes are not widely implemented.

AIMS

This study surveyed the views of UK-based speech and language therapists (SLTs) regarding intensive and comprehensive aphasia therapy. It explored definitions of intensive and comprehensive therapy, patterns of provision, views about candidacy and barriers/facilitators. It also investigated awareness of ICAPs and perceived potential of this service model. Differences across UK regions and workplace settings were explored.

METHODS & PROCEDURES

An e-survey ran for 5 months. Quantitative data were analysed using descriptive and inferential statistics. Qualitative free text comments were analysed using content analysis.

OUTCOMES & RESULTS

Two hundred twenty-seven respondents engaged in the e-survey. Definitions of intensive aphasia therapy did not reach UK clinical guideline/research-level thresholds for most of the sample. Those providing more therapy provided definitions with higher standards of intensity. Mean therapy delivered was 128 min/week. Geographical location and workplace setting influenced the amount of therapy delivered. The most frequently delivered therapy approaches were functional language therapy and impairment-based therapy. Cognitive disability and fatigue were concerns for therapy candidacy. Barriers included lack of resources and low levels of optimism that issues could be solved. 50% of respondents were aware of ICAPs and 15 had been involved in ICAP provision. Only 16.5% felt their service could be reconfigured to deliver an ICAP.

CONCLUSIONS & IMPLICATIONS

This e-survey evidences a mismatch between an SLT's concept of intensity and that espoused by clinical guidelines/research. Geographical variations in intensity are concerning. Although a wide range of therapy approaches are offered, certain aphasia therapies are delivered more frequently. Awareness of ICAPs was relatively high, but few respondents had experience of this model or felt it could be executed in their context. Further initiatives are needed if services are to move from a low-dose or non-comprehensive model of delivery. Such initiatives might include but not be confined to wider uptake of ICAPs. Pragmatic research might also explore which treatments are efficacious with a low-dose model of delivery, given that this model is dominant in the United Kingdom. These clinical and research implications are raised in the discussion.

WHAT THIS PAPER ADDS

What is already known on this subject There is a gap between the high intensity of aphasia treatment provided in research versus mainstream clinical settings. A lower standard of 45 min/day set by UK clinical guidelines is also not achieved. Although speech and language therapists (SLTs) provide a wide range of therapies, they typically focus on impairment-based approaches. What this study adds This is the first survey of UK SLTs asking about their concept of intensity in aphasia therapy and what types of aphasia therapy they provide. It explores geographical and workplace variations and barriers and facilitators to aphasia therapy provision. It investigates Intensive Comprehensive Aphasia Programmes (ICAPs) in a UK context. What are the clinical implications of this work? There are barriers to the provision of intensive and comprehensive therapy in the United Kingdom and reservations about the feasibility of ICAPs in a mainstream UK context. However, there are also facilitators to aphasia therapy provision and evidence that a small proportion of UK SLTs are providing intensive/comprehensive aphasia therapy). Dissemination of good practice is necessary and suggestions for increasing intensity of service provision are listed in the discussion.

Effect of intensive water resistance phonation therapy for people with presbyphonia: A pilot study

Purpose: The aim of this pilot study was to explore the efficacy of an intensive 3 week water resistance phonation (WRP) therapy program for people with presbyphonia.Method: Participants included 13 people with presbyphonia who received intensive WRP therapy. All participants completed eight sessions of therapy over 3 weeks. Auditory perceptual ratings, and acoustic and aerodynamic assessments were performed before and after treatment. Participants also completed the voice-related quality of life questionnaire before and after the treatment.Result: After 3 weeks of intensive voice therapy, significant improvements were demonstrated in acoustic, aerodynamic, and auditory perceptual parameters, as well as patient perceptions of voice-related quality of life. Acoustically, it was found there were significant decreases in shimmer (p = 0.019), noise-to-harmonic ratio (p = 0.016), and smoothed cepstral peak prominence (p = 0.001). Perceptually, the clients with presbyphonia showed significant reductions in the ratings of the overall grade, roughness, asthenia, and strain. Moreover, there was a significant increase in the total score of the Mandarin version of the Voice-Related Quality of Life measure post-therapy.Conclusion: The investigation provides preliminary evidence that people with presbyphonia can improve their vocal function and voice-related quality of life through intensive WRP therapy within a short period of time.

Bi-Weekly Voice Therapy Versus Weekly Voice Therapy for Muscle Tension Dysphonia

OBJECTIVES

To compare the outcomes of bi-weekly voice therapy (BWVT) with weekly voice therapy on perception, acoustics, and quality of life for individuals with muscle tension dysphonia (MTD).

METHODS

Thirty participants with MTD were enrolled either BWVT (40 min/session, two sessions per week for 4 weeks) or weekly voice therapy (40 min/session, once a week for 8 weeks). Auditory perceptual ratings, acoustic parameters, and the Mandarin version of the voice-related quality of life questionnaire (MV-RQOL) scores were statistically analyzed before and after treatment.

RESULTS

There were significant improvements in the voice qualities such as overall grade, roughness, asthenia, and strain in both groups after treatment. Acoustics analyses showed that fundamental frequency, speaking fundamental frequency, jitter, shimmer, and cepstral peak prominence significantly improved in both groups after treatment. For the MV-RQOL questionnaire scores, the result also demonstrated that both groups felt significant improvements in voice-related quality of life after treatment. However, there were no significant differences between the two groups of treatment effects.

CONCLUSIONS

Patients with MTD can restore voice qualities and quality of life if they are able to complete a full course of voice therapy, regardless of the intensity of voice therapy. However, if they can receive the BWVT, they would be able to regain their voice faster. The results of this study can be provided as a reference for clinicians when treating patients with MTD.

Investigating the Student in Returning to Learn After Concussion: A Systematic Review and Meta-Analysis

PURPOSE

Examine concussion effects on academic outcomes, including student perspectives.

METHODS

This study included a systematic review and meta-analysis examining post-concussion school attendance, academic performance, perceptions of academic difficulty, and accommodations for students in elementary through college settings. The analysis considered pre- and post-injury factors, along with injury factors that contribute to post-concussion academic outcomes.

RESULTS

The systematic review showed that students with concussion miss more school days and perceive higher levels of academic difficulty, but results about academic performance varied. Meta-analysis yielded small concussion effects on school absence and academic performance and moderate effects on perceptions of academic difficulty. Female sex, older age, history of migraine, prior concussions, severe or persistent symptoms, vestibular-ocular motor, and cognitive disruptions are risk factors, but these moderators were not identified in the meta-analysis due to lack of effect sizes.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

This study confirmed negative concussion effects on academic absences, performance, and perceptions of academic difficulty. Identified contributing factors will guide future practices to support students returning to learn after concussion.

CONCLUSIONS

Negative impacts to academics from concussion may be amplified by complicating factors. Future investigations are needed to confirm risk factors and mitigating effects of early identification and post-injury supports.

Dosages of swallowing exercises in stroke rehabilitation: a systematic review

PURPOSE

To investigate the dosages of swallowing exercises reported in intervention studies on post-stroke dysphagia through systematic review.

METHODS

Five electronic databases were searched from inception until February 2022 with reference tracing of included studies. Studies were included, where adults with post-stroke dysphagia received rehabilitative, behavioural swallowing exercises, pre/post outcomes were reported, and intervention dosage was described in detail, including frequency, intensity, time, and type of exercise. Two reviewers independently screened studies and rated quality using ASHA Levels of Evidence tool. Data was tabulated and narratively described.

RESULTS

54 studies were included with a total 1501 participants. Studies included 28 randomised controlled trials, 8 non-randomised controlled trials, 12 pre/post studies, 3 retrospective case controls and 3 case studies. Results showed inconsistent reporting of intervention dosage, with intensity the least consistently reported dosage component. While swallowing intervention was most commonly provided five times per week for four weeks, there was a wide breadth of type, frequency, intensity and duration of swallowing exercises reported. Dosage under-reporting and variation was particularly observed in "standard care" co-interventions or control groups. Study strengths included following PRISMA guidelines, providing a comprehensive review of swallowing exercise methodology and dosages, and including non-English studies. The limitation was lack of meta-analysis due to the heterogeneity of included studies.

CONCLUSIONS

Dosages of swallowing exercises are inconsistently reported and vary significantly in post-stroke dysphagia studies. Results indicate the need for consistent and comprehensive dosage reporting in dysphagia studies, and for further research into evidence-based principles to optimise swallowing exercise dosages.

SYSTEMATIC REVIEW REGISTRATION NUMBER

131294.

The Experiences of Trans and Gender Diverse Clients in an Intensive Voice Training Program: A Mixed-Methodological Study

Intensive schedules in behavioral voice therapy and training have been proposed to have a range of positive benefits including enhanced outcomes, high client and clinician satisfaction, and reduced client attrition. In the sub-field of behavioral voice training for trans and gender diverse clients, intensive schedules may also present a means of increasing service access opportunities for a vulnerable population. Despite the proposed benefits there has been limited research investigating client experiences in intensive voice training programs. The current study utilized a mixed-methodological approach to compare participant experiences in an intensively scheduled (three 45-minute sessions per week, over 4 weeks) versus a traditionally scheduled (one 45-minute session per week, over 12 weeks) voice training program for trans and gender diverse participants aiming to develop a perceptually feminine-sounding voice. Participant experiences were compared using a satisfaction questionnaire delivered to both training groups as well as thematic analysis of semi-structured interviews conducted with participants in the intensive group. Results suggested that individuals in the intensive training program had both positive and negative experiences related to the intensive schedule, but all viewed the program favorably and expressed a preference for intensive training based on their experiences. However, it was also found that overall satisfaction and attrition did not differ significantly between the intensive and traditional training groups and that many factors contributing to participant satisfaction in the intensive program were unrelated to the intensive schedule. Results from the current study also suggest that experiences in intensive programs may be highly variable and mediated by factors such as clients' individual personalities and preferences. The current study concludes that intensive schedules present a viable alternative to traditional schedules in practice, with additional considerations and directions for future research also discussed.

Speech treatment for Hebrew-speaking adolescents and young adults with developmental dysarthria: A comparison of mSIT and Beatalk

BACKGROUND

Individuals with developmental dysarthria typically demonstrate reduced functioning of one or more of the speech subsystems, which negatively impacts speech intelligibility and communication within social contexts. A few treatment approaches are available for improving speech production and intelligibility among individuals with developmental dysarthria. However, these approaches have only limited application and research findings among adolescents and young adults.

AIMS

To determine and compare the effectiveness of two treatment approaches, the modified Speech Intelligibility Treatment (mSIT) and the Beatalk technique, on speech production and intelligibility among Hebrew-speaking adolescents and young adults with developmental dysarthria.

METHODS & PROCEDURES

Two matched groups of adolescents and young adults with developmental dysarthria participated in the study. Each received one of the two treatments, mSIT or Beatalk, over the course of 9 weeks. Measures of speech intelligibility, articulatory accuracy, voice and vowel acoustics were assessed both pre- and post-treatment.

OUTCOMES & RESULTS

Both the mSIT and Beatalk groups demonstrated gains in at least some of the outcome measures. Participants in the mSIT group exhibited improvement in speech intelligibility and voice measures, while participants in the Beatalk group demonstrated increased articulatory accuracy and gains in voice measures from pre- to post-treatment. Significant increases were noted post-treatment for first formant values for select vowels.

CONCLUSIONS & IMPLICATIONS

Results of this preliminary study are promising for both treatment approaches. The differentiated results indicate their distinct application to speech intelligibility deficits. The current findings also hold clinical significance for treatment among adolescents and young adults with motor speech disorders and application for a language other than English.

WHAT THIS PAPER ADDS

What is already known on the subject Developmental dysarthria (e.g., secondary to cerebral palsy) is a motor speech disorder that negatively impacts speech intelligibility, and thus communication participation. Select treatment approaches are available with the aim of improving speech intelligibility in individuals with developmental dysarthria; however, these approaches are limited in number and have only seldomly been applied specifically to adolescents and young adults. What this paper adds to existing knowledge The current study presents preliminary data regarding two treatment approaches, the mSIT and Beatalk technique, administered to Hebrew-speaking adolescents and young adults with developmental dysarthria in a group setting. Results demonstrate the initial effectiveness of the treatment approaches, with different gains noted for each approach across speech and voice domains. What are the potential or actual clinical implications of this work? The findings add to the existing literature on potential treatment approaches aiming to improve speech production and intelligibility among individuals with developmental dysarthria. The presented approaches also show promise for group-based treatments as well as the potential for improvement among adolescents and young adults with motor speech disorders.

The Effectiveness of Gender Affirming Voice Training for Transfeminine Clients: A Comparison of Traditional Versus Intensive Delivery Schedules

INTRODUCTION

Gender affirming voice training is a service provided by speech language pathologists to members of the trans and gender diverse community. While there is some evidence to support the effectiveness of this training, the evidence base is limited by a lack of prospective studies with large sample sizes. Finally, there has been only limited research investigating the effectiveness of this training when delivered on intensive (compressed) schedules, even though such schedules are used in clinical practice and may have practical benefits such as increasing service access for this vulnerable population.

METHODOLOGY

This study aimed to investigate and compare the effectiveness gender affirming voice training among 34 trans individuals presumed male at birth who shared a goal of developing a 'female-sounding voice'. Among these 34 participants, 17 received their training on a traditional schedule (one 45-minute session per week over 12 weeks) and 17 on an intensive scheduled (three 45-minute sessions per week over 4 weeks). Building on a previous mixed methodological study which indicated that these two training groups were equally satisfied with training outcomes, the current study utilised a wide range of self-report, acoustic, and auditory-perceptual outcome measures (including self-ratings and listener-ratings of voice) to investigate training effectiveness.

DISCUSSION

Results from this study indicated that both training programs were similarly effective, producing positive statistically significant change among participants on a range of outcome measures. Participants in both groups demonstrated significant auditory-perceptual and acoustic voice change and reported increased satisfaction with voice, increased congruence between gender identity and expression, and a reduction in the negative impact of voice concerns on everyday life. However, as has been the case in past studies, training was not sufficient for all participants to achieve their specific goal of developing a consistently 'female-sounding voice'.

CONCLUSION

This study provides evidence to suggest that gender affirming voice training for transfeminine clients may be similalrly effective whether delivered intensively or traditionally. This study provides evidence to support the practice of using a wide range of outcome measures to gain holistic insight into client progress in gender affirming voice training programs.

Using the Experience Sampling Method to Examine the Details of Dosage in School-Based Speech Sound Therapy

PURPOSE

The purpose of this project was to collect practice-based evidence regarding dosage in speech sound therapy sessions in school-based settings. Dosage is the number of trials within a therapy session for any one particular child. School-based speech-language pathologists (SLPs) face a variety of obstacles to service delivery, often making the implementation of evidence-based practices difficult. To that end, we were interested in exploring how therapy parameters, such as group size and session frequency were associated with dosage.

METHOD

Using the experience sampling method, we queried school-based SLPs (n = 90) across the United States. SLPs participated via a phone application, which randomly alerted them to participate 3 times per day for 5 days. SLPs also completed a demographic questionnaire that included information regarding caseload size and job satisfaction.

RESULTS

We report results from 670 therapy sessions. Results revealed that the therapy parameter of group size was negatively related to dosage. The SLP parameter of caseload size was positively related to dosage, but this was a small association. The child parameter of comorbidity was negatively related to dosage.

CONCLUSIONS

Our results support that as group size increases, children receive smaller doses of speech sound practice. Similarly, children who have a reported comorbidity received smaller doses compared to children who have an isolated speech sound disorder. We discuss implications for school-based practitioners and researchers.

Behavioral interventions for poststroke aphasia

There is a long history of behavioral interventions for poststroke aphasia with hundreds of studies supporting the benefits of aphasia treatment. However, interventions for aphasia are complex with many interacting components, and no one treatment is appropriate for all persons with aphasia. We present a novel, simple framework for classifying aphasia interventions. The framework is incorporated within the overarching International Classification of Functioning, Disability, and Health (ICF) model and is consistent with the commonly-held definition that aphasia is a multimodality disorder that impairs, in varying degrees, the understanding and expression of both oral and written language modalities. Furthermore, within the language impairment level, it distinguishes between the linguistic areas of phonology, semantics, and syntax that may be impaired individually or in combination. We define the terminology of the proposed framework and then categorize some common examples of behavioral interventions for post-stroke aphasia. We describe some of these interventions in greater detail to illustrate the extensive toolbox of evidence-based treatments for aphasia. We address some key issues that clinicians, usually speech-language pathologists, consider when selecting interventions for their specific patients with aphasia, including dose. Finally, we address various models of service delivery for persons with aphasia such as Intensive Comprehensive Aphasia Programs (ICAPs) and Aphasia Centers.

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb and Sentence Deficits in Aphasia: Sentence Treatments

PURPOSE

This review article synthesizes and evaluates the evidence for sentence production treatments in aphasia, systematically charting impairment-based and functional communication outcomes. It reports (a) the level of evidence and fidelity of sentence treatments; (b) the impact of treatment on production of trained and untrained verbs and sentences, functional communication, and discourse; and (c) the potential active ingredients of treatment.

METHOD

The search included studies from January 1980 to June 2019. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to treatment methods used.

RESULTS

Thirty-three studies were accepted into the review and predominantly constituted Level 4 evidence (e.g., case control studies and case series). Thirty studies (90%) described treatment in sufficient detail to allow replication, but dosage was poorly reported, and fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were mapping (10 studies: 30%), predicate argument structure treatment (six studies: 18%), and verb network strengthening treatment (five studies: 15%). Production of trained sentences improved for 83% of participants, and improvements generalized to untrained sentences for 59% of participants. Functional communication was rarely assessed, but discourse production improved for 70% of participants.

CONCLUSIONS

The evidence for sentence treatments is predominantly generated from Level 4 studies. Treatments were effective for the majority of participants regarding trained sentence and discourse production. However, there is inconsistent use of statistical analysis to verify improvements, and diverse outcome measures are used, which makes interpretation of the evidence difficult. The quality of sentence treatment research would be improved by agreeing a core set of outcome measures and extended by ascertaining the views of participants on sentence treatments.

Frequency of Early Intervention Sessions and Vocabulary Skills in Children with Hearing Loss

BACKGROUND

A primary goal of early intervention is to assist children in achieving age-appropriate language skills. The amount of intervention a child receives is ideally based on his or her individual needs, yet it is unclear if language ability impacts amount of intervention and/or if an increased frequency of intervention sessions results in better outcomes. The purpose of this study was to determine the relationship between the frequency of early intervention sessions and vocabulary outcomes in young children with hearing loss.

METHODS

This was a longitudinal study of 210 children 9 to 36 months of age with bilateral hearing loss living in 12 different states. Expressive vocabulary skills were evaluated using the MacArthur-Bates Communicative Development Inventories.

RESULTS

A higher number of intervention sessions reported at the first assessment predicted better vocabulary scores at the second assessment, and more sessions reported at the second assessment predicted better scores at the third assessment. For each increase in the number of sessions reported, there was a corresponding, positive increase in vocabulary quotient. In contrast, children's vocabulary ability at an earlier time point did not predict intervention session frequency at a later point in time.

CONCLUSIONS

A significant prospective effect was apparent with more therapy sessions resulting in improved vocabulary scores 9 months later. These findings underscore the importance of early intervention. Pediatricians and other health care professionals can help apply these findings by counseling parents regarding the value of frequent and consistent participation in early intervention.

Active Ingredients of Voice Therapy for Muscle Tension Voice Disorders: A Retrospective Data Audit

Background: Although voice therapy is the first line treatment for muscle-tension voice disorders (MTVD), no clinical research has investigated the role of specific active ingredients. This study aimed to evaluate the efficacy of active ingredients in the treatment of MTVD. A retrospective review of a clinical voice database was conducted on 68 MTVD patients who were treated using the optimal phonation task (OPT) and sob voice quality (SVQ), as well as two different processes: task variation and negative practice (NP). Mixed-model analysis was performed on auditory–perceptual and acoustic data from voice recordings at baseline and after each technique. Active ingredients were evaluated using effect sizes. Significant overall treatment effects were observed for the treatment program. Effect sizes ranged from 0.34 (post-NP) to 0.387 (post-SVQ) for overall severity ratings. Effect sizes ranged from 0.237 (post-SVQ) to 0.445 (post-NP) for a smoothed cepstral peak prominence measure. The treatment effects did not depend upon the MTVD type (primary or secondary), treating clinicians, nor the number of sessions and days between sessions. Implementation of individual techniques that promote improved voice quality and processes that support learning resulted in improved habitual voice quality. Both voice techniques and processes can be considered as active ingredients in voice therapy.

The effects of intensity on a phonological treatment for anomia in post-stroke aphasia

INTRODUCTION

The evidence regarding optimal treatment intensity is mixed, and differing definitions have further confounded existing findings. The primary objective of this study was to compare the efficacy of Phonological Components Analysis (PCA) treatment for anomia delivered at intense and non-intense schedules, using a well-controlled design. The number of teaching episodes and active ingredients of therapy are important considerations when defining intensity. We hypothesized that an active ingredient of PCA is the self-generation of phonological components during therapy sessions. Our secondary aim was to examine whether component generation predicted treatment outcome.

METHODS

Sixteen adults (M = 52.63 years old, SD = 11.40) with chronic post-stroke aphasia (M = 4.52 years post-onset, SD = 5.55) were randomly assigned to intensive (IT) or standard (ST) PCA treatment conditions. Cumulative treatment intensity in both conditions was equivalent: ST participants received PCA 1 hour/day, 3 days/week for 10 weeks, whereas IT participants received PCA 3 hours/day, 4 days/week for 2.5 weeks. The primary outcome was naming accuracy on a set of treated and (matched) untreated words, measured pre- and post-treatment, and at four- and eight-week follow-ups.

RESULTS

IT and ST conditions were similarly efficacious. However, secondary analyses suggest an advantage for the IT condition in naming of the treated words immediately post-treatment, but not at follow-ups. The self-generation of phonological components emerged as a significant positive predictor of naming accuracy for both the treated and untreated words. However, this relationship did not reach significance once baseline anomia severity was accounted for.

CONCLUSIONS

Although replication in a larger sample is warranted, results suggest that PCA treatment is similarly efficacious when delivered at different intensities. Other factors related to the quality of treatment (i.e., active ingredients such as cue-generation) may play an important role in determining treatment efficacy and must also be considered when comparing treatment intensities.

Improving speech characteristics of young adults with congenital dysarthria: An exploratory study comparing articulation training and the Beatalk method

INTRODUCTION

This exploratory study compared the effects of two speech therapy approaches on speech characteristics of young adults with congenital dysarthria resulting from various etiologies: a) articulation training focusing on consonant articulation exercises at various levels (isolation, syllables, and words), and b) the Beatalk method, based on human beatboxing, i.e., producing various instrumental sounds in an a-cappella musical context. Both interventions were designed to increase participants' speech intelligibility.

METHODS

Twelve adults with congenital dysarthria and reduced speech intelligibility participated in treatment groups for eight weeks. Six participants were assigned to the articulation training group, and six to the Beatalk group. Intelligibility of single words and continuous speech, voice measures, and oral-diadochokinesis rates were measured before and after the treatment.

RESULTS

The results showed that the Beatalk intervention yielded a significant overall pre- to post-treatment effect. Specifically, it resulted in gains in articulatory accuracy and intelligibility for single words. Improvements were not noted following articulation training.

CONCLUSIONS

The results present initial evidence of the positive effect of the Beatalk method as an intervention tool for adults with congenital dysarthria. This relatively easy-to-learn technique shows promise, as it involves intense and repetitive production of speech sounds while controlling rhythm and breathing in an enjoyable context.

Hybrid Telepractice Delivery of Enhanced Milieu Teaching: Effects on Caregiver Implementation and Child Communication

Purpose This study investigated the effects of enhanced milieu teaching (EMT) on caregiver implementation of language support strategies and child communication skills using a hybrid telepractice service delivery model. Method Four caregivers and children with language delays aged 18-27 months participated in a multiple baseline across behaviors single-case research design. The therapist provided EMT to each caregiver-child dyad using a hybrid telepractice service delivery model with approximately 40% in-person and 60% telepractice sessions. Caregivers were taught to use five EMT language support strategies: matched turns, target talk, expansions, time delays, and milieu teaching episodes. Caregiver instruction followed the Teach-Model-Coach-Review approach. Caregiver outcomes were two measures of EMT implementation fidelity, accuracy, and frequency of EMT strategy use. Accuracy was measured by the percentage of spoken turns in which caregivers used each strategy correctly. Frequency was measured by the number of spoken turns in which caregivers used each strategy correctly. Child outcomes were number of communication acts, weighted count of communication acts, and number of different words. Results There was a functional relation between the intervention and the accuracy of EMT strategy use for all four dyads, and the frequency of strategy use for three dyads. Caregiver use of EMT strategies maintained for 6 weeks post-intervention. After caregivers learned EMT strategies, gradual increases in the number of communication acts, weighted count of communication acts, and number of different words occurred for three children. Conclusion Results demonstrate the preliminary efficacy of using a hybrid telepractice service delivery model to teach caregivers EMT language support strategies. Supplemental Material https://doi.org/10.23641/asha.14977605.

Vocabulary Acquisition and Usage for Late Talkers Treatment: Effect on Expressive Vocabulary and Phonology

Purpose This study examined the effect of Vocabulary Acquisition and Usage for Late Talkers (VAULT) treatment on toddlers' expressive vocabulary and phonology. Parent acceptability of VAULT treatment was also considered. Method We used a nonconcurrent multiple baseline single case experimental design with three late talking toddlers aged 21-25 months. The treatment was delivered twice weekly in 30-min sessions for 8 weeks by a rotating team of four speech-language pathologists. Toddlers heard three of their 10 strategically selected target words a minimum of 64 times in play activities each session. Expressive vocabulary and phonology was assessed pre-post, with parent interviews conducted posttreatment. Results All toddlers increased production of target words and expressive vocabulary. Ambient expressive vocabulary size increased by an average of 16 words per week (range of 73-169 words learned over the treatment period). On a 20-item, single-word speech assessment, the toddlers' phonetic inventories increased on average from three to seven consonants, and five to eight vowels. Two toddlers used protowords pretreatment, which were replaced by recognizable attempts at words posttreatment. Parents reported the treatment was acceptable for the child and their family with future consideration of parent-based delivery of the treatment in the home. Conclusions The results of this treatment provide further evidence of a model of intervention informed by the principles of implicit learning, and the interconnectedness of phonological and lexical learning. Investigation is required to establish the efficacy and feasibility of VAULT in clinical contexts. Supplemental Material https://doi.org/10.23641/asha.14714733.

Effectiveness of Intensive Voice Therapy Versus Weekly Therapy for Muscle Tension Dysphonia: A Noninferiority Randomised Controlled Trial With Nested Focus Group

OBJECTIVES

To investigate the noninferiority of intensive voice therapy and compare its effects with weekly voice therapy on multidimensional outcomes of voice and well-being, satisfaction, and attendance in people with muscle tension dysphonia (MTD). The study further aimed to explore clinician's perceptions of barriers and enablers to implementation of intensive therapy.

STUDY DESIGN

Noninferiority randomised controlled trial with nested focus group.

METHODS

Twenty adults with MTD were randomised to receive either weekly voice therapy (1 hour per week for 8 weeks) or intensive voice therapy (1 hour, 4 days per week for 2 weeks). Participants were assessed by a blinded assessor twice before treatment, once post treatment and once at 4 weeks follow up on the primary outcome measure VHI and a range of secondary auditory-perceptual, acoustic, and patient (i.e., VoiSS, satisfaction) and clinician reported outcome measures (i.e., AusTOMs, attendance rates). Five Speech Language Pathologists also participated in a focus group to explore barriers and enablers to implementing intensive therapy, with questions and analyses guided by the Theoretical Domains Framework.

RESULTS

While noninferiority for the primary outcome measure VHI was not confirmed, secondary outcome measures revealed comparable within group clinically important improvements for VoiSS and the AusTOMs, as well as selected acoustic and auditory-perceptual measures for both groups. A trend of more improvements being maintained in the intensive group was identified. Comparably high satisfaction and attendance was also found between groups. Clinicians reported more enablers than barriers to providing intensive therapy which included beliefs that it led to greater progression and consolidation of patient learning, was supported by the local context and was associated with positive emotions. Barriers related to difficulties with booking and scheduling and the belief that intensive therapy was not for all patients.

CONCLUSIONS

While the current study was likely underpowered to establish non-inferiority of intensive therapy, secondary outcomes suggested that intensive therapy may produce comparable benefits to voice, wellbeing, satisfaction and attendance compared to weekly therapy and may be a viable therapy option for individuals with MTD. When implementing intensive therapy, clinicians should consider patient's preferences and availability, as well as systems which allow for flexible booking and therapy provision for patients. Clear recommendations for future research including the use of a larger sample and telehealth are also provided.

The Value of Rehabilitation Interventions --Integrating Evidence, Clinical Expertise, Critical Assessment, and , Patient Needs: A Conference Report

In order to understand issues related to value, outcomes, and cost-effectiveness of rehabilitation interventions, and to explore how scientific evidence, clinical expertise, and patient needs can be integrated, the Rehabilitation Research and Training Center on Developing Optimal Strategies in Exercise and Survival Skills to Increase Health and Function held a State of the Science (SOS) Symposium on "The Value of Rehabilitation Interventions" at Shirley Ryan AbilityLab in Chicago in 2017. In this conference, the perspectives of 35 invited experts, including people with disabilities, professionals, and consumers, explored the topic of "value" of rehabilitation interventions and discussed their perspectives on the means to integrate best scientific evidence with clinical expertise and patient preferences. This Symposium also resulted in the production of several multifaceted manuscripts providing perspectives on the topic of value and how to use evidence to best determine and demonstrate it. These papers comprise this Supplement. The present paper introduces the key concepts of value, evidence, and knowledge translation, in an effort to provide a context for the papers of the Supplement.

How to Recruit, Support, and Retain Speech-Language Pathologists in Public Schools

Over the past two decades, there has been a persistent shortage of qualified speech-language pathologists (SLPs) across the United States. This shortage is predicted to continue, as data reported by the American Speech Language Hearing Association (ASHA) from the US Bureau of Labor Statistics indicates that there will be a 27% increase in job openings through the year 2028. In some states, the shortage has led to service provision from individuals without a background in speech-language pathology and/or without speech-language pathology certification and licensure. Speech and language services that are delivered by unqualified personnel may lead to inadequate time devoted to therapy—either too much, or too little—which is ultimately unethical, illegal, and expensive. However, there is a real issue at hand for school leadership—and that is: How to recruit, support, and retain highly qualified SLPs? In the current tutorial, we will provide evidence-based action steps for how and why to recruit, support, and retain certified and licensed SLPs. Specifically, we discuss the qualifications of the SLP, roles and responsibilities of school-based SLPs, caseload versus workload considerations, various service delivery models, and a review of SLP job satisfaction research. Throughout the tutorial, we will provide concrete and evidence-based ideas for school leadership to consider when recruiting, supporting, and retaining SLPs.

Implementation of a Home-Based mHealth App Intervention Program With Human Mediation for Swallowing Tongue Pressure Strengthening Exercises in Older Adults: Longitudinal Observational Study

Background

Tongue pressure is an effective index of swallowing function, and it decreases with aging and disease progression. Previous research has shown beneficial effects of swallowing exercises combined with myofunctional tongue-strengthening therapy on tongue function. Tongue exercises delivered through mobile health (mHealth) technologies have the potential to advance health care in the digital age to be more efficient for people with limited resources, especially older adults.

Objective

The purpose of this study is to explore the immediate and long-term maintenance effects of an 8-week home-based mHealth app intervention with biweekly (ie, every 2 weeks) human mediation aimed at improving the swallowing tongue pressure in older adults.

Methods

We developed an mHealth app intervention that was used for 8 weeks (3 times/day, 5 days/week, for a total of 120 sessions) by 11 community-dwelling older adults (10 women; mean age 75.7 years) who complained of swallowing difficulties. The app included a swallowing monitoring and intervention protocol with 3 therapy maneuvers: effortful prolonged swallowing, effortful pitch glide, and effortful tongue rotation. The 8-week intervention was mediated by biweekly face-to-face meetings to monitor each participant’s progress and ability to implement the training sessions according to the given protocol. Preintervention and postintervention isometric and swallowing tongue pressures were measured using the Iowa Oral Performance Instrument. We also investigated the maintenance effects of the intervention on swallowing tongue pressure at 12 weeks postintervention.

Results

Of the 11 participants, 8 adhered to the home-based 8-week app therapy program with the optimal intervention dosage. At the main trial end point (ie, 8 weeks) of the intervention program, the participants demonstrated a significant increase in swallowing tongue pressure (median 17.5 kPa before the intervention and 26.5 kPa after the intervention; P=.046). However, long-term maintenance effects of the training program on swallowing tongue pressure at 12 weeks postintervention were not observed.

Conclusions

Swallowing tongue pressure is known to be closely related to dysphagia symptoms. This is the first study to demonstrate the effectiveness of the combined methods of effortful prolonged swallowing, effortful pitch glide, and effortful tongue rotation using mobile app training accompanied by biweekly human mediation in improving swallowing tongue pressure in older adults. The mHealth app is a promising platform that can be used to deliver effective and convenient therapeutic service to vulnerable older adults. To investigate the therapeutic efficacy with a larger sample size and observe the long-term effects of the intervention program, further studies are warranted.

International Registered Report Identifier (IRRID)

RR2-10.2196/19585

Comparing higher and lower weekly treatment intensity for chronic aphasia: A systematic review and meta-analysis

Optimizing intensity for aphasia treatment is a high priority research issue for people with aphasia, their families and clinicians, and could result in healthcare cost savings. An important aspect of intensity is the frequency of intervention, or how regularly treatment should be provided each week. While principles of neuroplasticity endorse massed practice, cognitive psychology has established superiority of distributed practice within normal learning. Neither concept has been conclusively tested in aphasia. There have been many literature reviews of intensity in aphasia intervention, but most have not investigated treatment intensity whilst also ensuring that therapy dose and treatment type are identical between study groups. Some have also combined studies across acute, subacute and chronic aphasia. We searched systematically for studies directly comparing higher and lower weekly treatment frequency in chronic aphasia. Eight studies were retrieved and rated for methodological quality. Meta-analysis was completed for group and single case experimental designs. Results showed that there are few studies investigating treatment frequency in chronic aphasia and their quality is low-moderate. Meta-analyses were inconclusive due to limited data, but there was no indication of either schedule being superior. Further research directly comparing treatment schedules is needed.

Contributions to Gain in Speech Sound Production Accuracy for Children With Speech Sound Disorders: Exploring Child and Therapy Factors

Purpose The purpose of this study was to explore the extent to which child- and therapy-level factors contribute to gains in speech sound production accuracy for children with speech sound disorders in receipt of school-based services. Method Data were obtained from 126 kindergarten and first- and second-grade children currently in receipt of speech therapy services in their public school setting. Pretest and posttest measures of spontaneous speech production and language ability were collected at the beginning and end of one academic year. Using a spontaneous speech sample, percentage of consonants correct (PCC) was calculated for each child; a gain score was computed by subtracting the pretest PCC score from the posttest PCC score. The children's speech-language pathologist completed weekly therapy logs during business-as-usual therapy, indicating the frequency, duration, and group composition of services throughout the school year. Results Results supported that gain in PCC from pretest to posttest was predicted by several child- and therapy-level variables. Children's initial speech sound severity was negatively related to gains in PCC. Our results also supported that the total number of therapy sessions received in a year was positively predictive of PCC gain. Interestingly, the number of individual therapy sessions was negatively associated with PCC gain. Conclusion Several malleable therapy factors contribute to gains in speech sound accuracy for children with speech sound disorders. Speech-language pathologists should consider how these factors may be manipulated to best tailor treatment to the individual needs of the children on their caseloads.

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb Deficits in Aphasia: Verb-in-Isolation Treatments

Purpose Aphasia research demonstrates increasing interest in the treatment of verb retrieval deficits. This systematically conducted scoping review reports on the level and fidelity of the current evidence for verb treatments; on its effectiveness regarding the production of trained and untrained verbs, functional communication, sentences, and discourse; and on the potential active ingredients. Recommendations to guide clinical decision making and future research are made. Method The computerized database search included studies from January 1980 to September 2018. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to the treatment methods used. Results Thirty-seven studies were accepted into the review, and all but 1 constituted a low level of evidence. Thirty-three studies (89%) described treatment in sufficient detail to allow replication, dosage was poorly reported, and the fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were phonological and semantic cueing in 25 (67.5%) and 20 (54%) studies, respectively. Retrieval of trained verbs improved for 80% of participants, and improvements generalized to untrained verbs for 15% of participants. There was not sufficient detail to evaluate the impact of treatment on sentence production, functional communication, and discourse. Conclusions The evidence for verb treatments is predominantly of a low level. There are encouraging findings in terms of treatments being replicable; however, this is tempered by poor monitoring of treatment fidelity. The quality of verb treatment research would be improved by researchers reaching consensus regarding outcome measures (including generalization to, e.g., sentences and discourse) by manualizing treatment to facilitate implementation and exploring the opinions of participants. Finally, while treatment is largely effective in improving production of trained verbs, lack of generalization to untrained items leads to the recommendation that personally relevant verbs are prioritized.

Feasibility of Automatic Speech Recognition for Providing Feedback During Tablet-Based Treatment for Apraxia of Speech Plus Aphasia

Purpose Individuals with neurogenic speech disorders require ongoing therapeutic support to achieve functional communication goals. Alternative methods for service delivery, such as tablet-based speech therapy applications, may help bridge the gap and bring therapeutic interventions to the patient in an engaging way. The purpose of this study was to evaluate an iPad-based speech therapy app that uses automatic speech recognition (ASR) software to provide feedback on speech accuracy to determine the ASR's accuracy against human judgment and whether participants' speech improved with this ASR-based feedback. Method Five participants with apraxia of speech plus aphasia secondary to stroke completed an intensive 4-week at-home therapy program using a novel word training app with built-in ASR. Multiple baselines across participants and behaviors designs were employed, with weekly probes and follow-up at 1 month posttreatment. Four sessions a week of 100 practice trials each were prescribed, with 1 being clinician-run and the remainder done independently. Dependent variables of interest were ASR-human agreement on accuracy during practice trials and human-judged word production accuracy over time in probes. Also, user experience surveys were completed immediately posttreatment. Results ASR-human agreement on accuracy averaged ~80%, which is a common threshold applied for interrater agreement. All participants demonstrated improved word production accuracy over time with the ASR-based feedback and maintenance of gains after 1 month. All participants reported enjoying using the app with support of a speech pathologist. Conclusion For these participants with apraxia of speech plus aphasia due to stroke, satisfactory gains were made in word production accuracy with an app-based therapy program providing ASR-based feedback on accuracy. Findings support further testing of this ASR-based approach as a supplement to clinician-run sessions to assist clients with similar profiles in achieving higher amount and intensity of practice as well as empowering them to manage their own therapy program. Supplemental Material https://doi.org/10.23641/asha.8206628.

Investigating intervention dose frequency for children with speech sound disorders and motor speech involvement

BACKGROUND

Treatment outcome data for children with severe speech sound disorders with motor speech involvement (SSD-MSI) are derived from Phase I clinical research studies. These studies have demonstrated positive improvements in speech production. Currently there is no research examining the optimal treatment dose frequency for this population. The results of this study, which is the first of its kind, will inform the delivery of effective services for this population.

AIMS

To investigate optimal treatment dose frequency for the Motor Speech Treatment Protocol (MSTP) for children with SSD-MSI.

METHODS & PROCEDURES

A total of 48 children (aged 43-47 months) with SSD-MSI participated in the study. Participants received 45-min MSTP intervention sessions either once per week (lower dose frequency) or twice per week (higher dose frequency) for a 10-week period. Blinded outcome assessments were carried out at pre- and post-intervention.

OUTCOMES & RESULTS

Treatment-related change was assessed at body structures, functions and activities participation level as per the World Health Organization's International Classification of Functioning framework: Children and Youth Version (ICF-CY) framework WHO (2007). These measures are related to articulation, functional communication and speech intelligibility. One-way analysis of variance (ANOVA) revealed that for all variables the baseline scores were not statistically different (p > 0.05) between the two dose-frequency groups. Overall, there was a significant main effect of Time (pre-post) across all variables (p < 0.01). However, repeated-measures ANOVA did not result in any statistical interactions (Time × Dose frequency) for any of the variables tested (p > 0.05). Only marginal clinical advantages (< 4% change in intelligibility) were noted with the 10 extra sessions.

CONCLUSIONS & IMPLICATIONS

Overall, the MSTP intervention approach in conjunction with home practice led to significant positive changes for all measures in children with SSD-MSI. No statistical differences between high- and low-dose-frequency groups were observed for any of the variables. Clinical effects were examined using effect sizes, as well as changes in articulation, speech intelligibility and functional communication; these differed marginally between the two dose frequencies. This suggests limited benefits of 10 additional sessions per block. Thus, it is recommended that caregivers, speech-language therapists and policy-makers perform a cost-benefit analysis before determining the dose frequency, when considering additional sessions per block.

Principles of Motor Learning in Classical Singing Teaching

INTRODUCTION

Classical singing is a complex and multifaceted skill that requires the amalgamation of multiple cognitive, perceptual and motor functions. The teaching of classical singing is consequently a unique skill that holds further complexity. The singer is required to achieve and maintain consistently high performance development of a specific motor activity, much like the sports athlete. This pilot study examines a method of using the principles of motor learning to more objectively and reliably investigate the teaching behaviors of classical singing teachers. Such a method may establish a nexus between empirical research, teaching quality and learning outcomes in music performance education.

METHOD

A total of 12 participants were recruited from two Australian conservatoria of music. All participants were fluent in English at tertiary level. Participants included four classical singing teachers and eight classical singing students over the age of 18 years. Eight one-to-one singing lessons between the teacher and student were audio-visually recorded. Content analysis was conducted on the observational data. The principles of motor learning were used as a behavioral framework protocol to allow for the systematic identification of teaching behavior.

RESULTS

Results presented various findings regarding teaching behaviors in one-to-one classical singing lessons in higher music education. Key findings included (a) common use of instruction, feedback, modeling, and other behaviors (b) uncommon use of motivation, explanation, and perceptual training behaviors, (c) higher use of knowledge of results than knowledge of performance feedback behaviors, (d) high routine use of instruction, modeling, and feedback behaviors each time a student attempted a task, (e) common use of other suggested teachers use behaviors unidentifiable by the behavioral protocol, and (f) the principles of motor learning appear to be a reliable framework for the identification of teaching behaviors in this field.

CONCLUSION

This study may have implications for how teachers administer and govern their behaviors in one-to-one classical singing lessons. The principles of motor learning may encourage a nexus between empirical research, teaching quality, and learning outcomes. Furthermore, this study provides recommendations for future research on systematically improving teaching and learning in this field.

Speech Intervention Outcomes Associated With Word Lexicality and Intervention Intensity

Purpose This study examined how lexical representations and intervention intensity affect phonological acquisition and generalization in children with speech sound disorders. Method Using a single-subject multiple baseline design, 24 children with speech sound disorders (3;6 to 6;10 [years;months]) were split into 3 word lexicality types targeting word-initial complex singleton phonemes: /ɹ l ʧ θ/. Specifically, academic vocabulary words, nonwords (NWs), and high-frequency (HF) words were contrasted. Intervention intensity was examined by comparing the performance of 12 children who completed eleven 50-min sessions (4 children/word type) to the performance of 12 who completed 19 sessions (4 children/word type). Children's production accuracy of their treated phonemes and overall percent consonants correct values were used to measure phonological generalization via percentage accuracy scores and d scores. Results All word lexicality conditions elicited phonological change, suggesting that academic vocabulary words, NWs, and HF words are viable intervention targets. Group mean averages were similarly high for the NWs and HF words, although children in the NW condition demonstrated more consistent phonological gains. Children who received 19 intervention sessions achieved 6 times more gains in treated sound accuracy than did children who received 11 sessions. Conclusions Word lexicality did not significantly influence children's intervention outcomes. More intensive intervention, as characterized by the number sessions, resulted in greater phonological change than did a shorter intervention program. Intervention intensity outcomes should be considered when establishing best practices for speech intervention scheduling. Supplemental Material https://doi.org/10.23641/asha.7336055.

Automated speech analysis tools for children's speech production: A systematic literature review

PURPOSE

A systematic search and review of published studies was conducted on the use of automated speech analysis (ASA) tools for analysing and modifying speech of typically-developing children learning a foreign language and children with speech sound disorders to determine (i) types, attributes, and purposes of ASA tools being used; (ii) accuracy against human judgment; and (iii) performance as therapeutic tools.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Across nine databases, 32 articles published between January 2007 and December 2016 met inclusion criteria: (i) focussed on children's speech; (ii) tools used for speech analysis or modification; and (iii) reporting quantitative data on accuracy.

RESULT

Eighteen ASA tools were identified. These met the clinical threshold of 80% agreement with human judgment when used as predictors of intelligibility, impairment severity, or error category. Tool accuracy was typically <80% accuracy for words containing mispronunciations. ASA tools have been used effectively to improve to children's foreign language pronunciation.

CONCLUSION

ASA tools show promise for automated analysis and modification of children's speech production within assessment and therapeutic applications. Further work is needed to train automated systems with larger samples of speech to increase accuracy for assessment and therapeutic feedback.

Stroke communication partner training: a national survey of 122 clinicians on current practice patterns and perceived implementation barriers and facilitators

BACKGROUND

Communication partners (CPs) find it challenging to communicate with people with communication disorders post-stroke. Stroke communication partner training (CPT) can enhance CPs' ability to support the communication and participation of people post-stroke. While evidence for the efficacy of aphasia-based CPT is strong, implementation in healthcare settings is unclear.

AIMS

To investigate Australian speech pathologists' current stroke CPT practices, factors influencing the implementation of CPT and how reported practice compares with the research evidence.

METHODS & PROCEDURES

Speech pathologists in Australia who had worked with people post-stroke were invited to complete a 99-item online survey. The survey was informed by a comprehensive review of the literature review, the Template for Intervention Description and Replication (TIDieR) intervention taxonomy, and the theoretical domains framework. data were analyzed using descriptive statistics and content analysis.

OUTCOMES & RESULTS

A total of 122 clinicians were surveyed. Most participants reported providing CPT to treat a range of post-stroke communication disorders. While 98.3% reported training familiar CPs, only 66.1% reported training unfamiliar CPs. Current stroke CPT practice is characterized by one to two < 1 h sessions of informal face-to-face education and skills training. Only 13.3% and 10.0% of participants used evidence-based published programmes with unfamiliar and familiar CPs respectively. The main barriers included the perceived lack of behavioural regulation, skills, reinforcement, beliefs about consequences, positive social influences and resources. The main facilitators included clinicians' intentions to provide CPT, perception of CPT as part of their role and perceived compatibility of CPT with clinical practice.

CONCLUSION & IMPLICATIONS

A significant evidence-practice gap exists. Research exploring the implementation of stroke CPT in healthcare settings, expanding evidence to support CPT for the range of post-stroke communication disorders, developing freely accessible step-by-step CPT programmes that consider restrictions in current practice and providing explicit instructions of CPT best practice are warranted. A supportive workplace culture and freely accessible formal training opportunities are also needed.

Speech treatment in Parkinson's disease: Randomized controlled trial (RCT)

BACKGROUND

As many as 89% of people with Parkinson's disease (PD) develop speech disorders.

OBJECTIVES

This randomized controlled trial evaluated two speech treatments for PD matched in intensive dosage and high-effort mode of delivery, differing in subsystem target: voice (respiratory-laryngeal) versus articulation (orofacial-articulatory).

METHODS

PD participants were randomized to 1-month LSVT LOUD (voice), LSVT ARTIC (articulation), or UNTXPD (untreated) groups. Speech clinicians specializing in PD delivered treatment. Primary outcome was sound pressure level (SPL) in reading and spontaneous speech, and secondary outcome was participant-reported Modified Communication Effectiveness Index (CETI-M), evaluated at baseline, 1, and 7 months. Healthy controls were matched by age and sex.

RESULTS

At baseline, the combined PD group (n = 64) was significantly worse than healthy controls (n = 20) for SPL (P < 0.05) and CETI-M (P = 0.0001). At 1 and 7 months, SPL between-group comparisons showed greater improvements for LSVT LOUD (n = 22) than LSVT ARTIC (n = 20; P < 0.05) and UNTXPD (n = 22; P < 0.05). Sound pressure level differences between LSVT ARTIC and UNTXPD at 1 and 7 months were not significant (P > 0.05). For CETI-M, between-group comparisons showed greater improvements for LSVT LOUD and LSVT ARTIC than UNTXPD at 1 month (P = 0.02; P = 0.02). At 7 months, CETI-M between-group differences were not significant (P = 0.08). Within-group CETI-M improvements for LSVT LOUD were maintained through 7 months (P = 0.0011).

CONCLUSIONS

LSVT LOUD showed greater improvements than both LSVT ARTIC and UNTXPD for SPL at 1 and 7 months. For CETI-M, both LSVT LOUD and LSVT ARTIC improved at 1 month relative to UNTXPD. Only LSVT LOUD maintained CETI-M improvements at 7 months. © 2018 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Intervention for children with phonological impairment: Knowledge, practices and intervention intensity in the UK

BACKGROUND

Across the world, research has shown that intervention for children with phonological impairment can be both effective and efficient. However, it has also raised concerns about the translation of this evidence to practice, highlighting questions around clinician knowledge and the understanding of approaches, and the intensity of intervention provided within real-life clinical contexts.

AIMS

To investigate the clinical management of phonological impairment by speech and language therapists (SLTs) in the United Kingdom (UK).

METHODS & PROCEDURES

An anonymous, UK-wide, online survey was developed using Qualtrics. The target audience were UK-based SLTs who worked with children with phonological impairment. The following topics were explored: (1) SLTs' understanding of intervention approaches; (2) SLTs' use of intervention approaches to treat phonological impairment; and (3) SLTs' provision of intervention intensity for children with phonological impairment.

OUTCOMES & RESULTS

A total of 166 responses were analyzed. To remediate phonological impairment, SLTs most commonly used speech discrimination (79.5%), conventional minimal pairs (77.3%), phonological awareness therapy (75.6%) and traditional articulation therapy (48.4%). Participants least frequently used the complexity approaches targeting the empty set (82.9%) and two- to three-element clusters (75%) as well as the cycles approach (75.6%). Results also showed that some SLTs were uncertain of what the empty set and two- to three-element clusters approaches entailed. In terms of intervention intensity, participants predominantly provided intervention once per week (69%) for a total of 9-12 sessions (ranging from five to 30 sessions, 71.5%) and elicited targets 10-30 times in single words per session (59.4%) in sessions lasting 21-30 min (41.4%).

CONCLUSIONS & IMPLICATIONS

The most commonly used intervention approaches identified in the current survey (i.e., speech discrimination, conventional minimal pairs and phonological awareness therapy) may be used eclectically by SLTs, which could impact upon the effectiveness and efficiency of treatment for phonological impairment. The current study also highlighted that almost half the participants always/often used traditional articulation therapy to remediate phonological impairment, even though this approach has been found to be less effective for this difficulty. Additionally, it appears that the currently provided intervention intensity for phonological impairment in the UK is significantly lower than what is indicated in the literature. Therefore, a research-practice gap exists for SLTs in the UK working with children with phonological impairment.

Cluster-Randomized Controlled Trial Evaluating the Effectiveness of Computer-Assisted Intervention Delivered by Educators for Children With Speech Sound Disorders

PURPOSE

The aim was to evaluate the effectiveness of computer-assisted input-based intervention for children with speech sound disorders (SSD).

METHOD

The Sound Start Study was a cluster-randomized controlled trial. Seventy-nine early childhood centers were invited to participate, 45 were recruited, and 1,205 parents and educators of 4- and 5-year-old children returned questionnaires. Children whose parents and educators had concerns about speech were assessed (n = 275); 132 children who were identified with phonological pattern-based errors underwent additional assessment. Children with SSD and no difficulties with receptive language or hearing, typical nonverbal intelligence, and English as their primary language were eligible; 123 were randomized into two groups (intervention n = 65; control n = 58), and 3 withdrew. The intervention group involved Phoneme Factory Sound Sorter software (Wren & Roulstone, 2013) administered by educators over 9 weeks; the control group involved typical classroom practices. Participants were reassessed twice by a speech-language pathologist who was unaware of the initial assessment and intervention conditions.

RESULTS

For the primary outcome variable (percentage of consonants correct), the significant mean change from pre- to postintervention for the intervention group (mean change = +6.15, p < .001) was comparable in magnitude to the significant change for the control group (mean change = +5.43, p < .001) with a small between-groups effect size for change (Cohen's d = 0.08). Similar results occurred for measures of emergent literacy, phonological processing, participation, and well-being.

CONCLUSION

Computer-assisted input-based intervention administered by educators did not result in greater improvement than typical classroom practices.

Implementation fidelity of a computer-assisted intervention for children with speech sound disorders

BACKGROUND

Implementation fidelity refers to the degree to which an intervention or programme adheres to its original design. This paper examines implementation fidelity in the Sound Start Study, a clustered randomised controlled trial of computer-assisted support for children with speech sound disorders (SSD).

METHOD

Sixty-three children with SSD in 19 early childhood centres received computer-assisted support (Phoneme Factory Sound Sorter [PFSS] - Australian version). Educators facilitated the delivery of PFSS targeting phonological error patterns identified by a speech-language pathologist. Implementation data were gathered via (1) the computer software, which recorded when and how much intervention was completed over 9 weeks; (2) educators' records of practice sessions; and (3) scoring of fidelity (intervention procedure, competence and quality of delivery) from videos of intervention sessions.

RESULT

Less than one-third of children received the prescribed number of days of intervention, while approximately one-half participated in the prescribed number of intervention plays. Computer data differed from educators' data for total number of days and plays in which children participated; the degree of match was lower as data became more specific. Fidelity to intervention procedures, competency and quality of delivery was high.

CONCLUSION

Implementation fidelity may impact intervention outcomes and so needs to be measured in intervention research; however, the way in which it is measured may impact on data.

Intensive Language Action Therapy in Chronic Aphasia: A Randomized Clinical Trial Examining Guidance by Constraint

Purpose

Intensive language action therapy (ILAT) can be effective in overcoming learned nonuse in chronic aphasia. It is suggested that all three guiding principles (constraint, communication embedding, massed practice) are essential to ILAT's success. We examined whether one of these, guidance by constraint, is critical.

Method

Twenty-four participants with aphasia (PWAs) were assigned to ILAT or a modified version of promoting aphasic communicative effectiveness (PACE) in a randomized block, single-blind, parallel-group treatment study. Blocking was by severity (mild/moderate, moderate to severe, severe). Both groups received intensive treatment in the context of therapeutic language action games. Whereas the ILAT group was guided toward spoken responses, the PACE group could choose any response modality.

Results

All participants, whether assigned to ILAT or PACE groups, improved on the primary outcome measure, picture naming. There was a Severity × Treatment interaction, with the largest effects estimated for PWAs with mild/moderate and moderate to severe aphasia. Regardless of severity, the ILAT group outperformed the PACE group on untrained pictures, suggesting some benefit of ILAT to generalization. However, this difference was not statistically significant.

Conclusion

Although the groups differed in subtle ways, including better generalization to untrained pictures for ILAT, the study was inconclusive on the influence of guidance by constraint.

Constraint-Induced Aphasia Therapy in the Acute Stage

Background. Constraint-induced aphasia therapy (CIAT) has proven effective in patients with subacute and chronic forms of aphasia. It has remained unclear, however, whether intensity of therapy or constraint is the relevant factor. Data about intensive speech and language therapy (SLT) are conflicting. Objective. To identify the effective component of CIAT and assess the feasibility of SLT in the acute stage after stroke. Method. A total of 60 patients with aphasia (68.2 ± 11.7 years) were enrolled 18.9 days after first-ever stroke. They were randomly distributed into 3 groups: (1) CIAT group receiving therapy for 3 hours per day (10 workdays, total 30 hours); (2) conventional communication treatment group, with same intensity without constraints; and (3) control group receiving individual therapy twice a day as well as group therapy (total 14 hours). Patients were assessed pretreatment and posttreatment using the Aachener Aphasia Test (primary end point: token test) and the Communicative Activity Log (CAL). Results. Pretreatment, there were no between-group differences. Posttreatment, all groups showed significant improvements without between-group differences. Conclusion. It was found that 14 hours of aphasia therapy administered within 2 weeks as individual therapy, focusing on individual deficits, combined with group sessions has proven to be most efficient. This approach yielded the same outcome as 30 hours of group therapy, either in the form of CIAT or group therapy without constraints. SLT in an intensive treatment schedule is feasible and was well tolerated in the acute stage after stroke.

Increasing aphasia treatment intensity in an acute inpatient rehabilitation program: A feasibility study

BACKGROUND

Intensity of therapy is a critical factor influencing outcomes in aphasia. However, there are many barriers to increasing treatment intensity for those with acute/subacute aphasia including the demands of the inpatient medical facilities and the endurance of the participants. Nevertheless, with some modifications to its original procedures, evidence suggests that Constraint Induced Language Therapy (CILT) may yield positive outcomes when given in the early stages of recovery.

AIMS

To investigate the feasibility of increasing the amount of therapy provided to individuals with aphasia on an inpatient rehabilitation unit by adding CILT at a modified intensity, and to assess whether those receiving two weeks of the additional CILT show more improvement than control participants who did not receive the additional treatment.

METHODS AND PROCEDURES

A case-series single-subject design study was conducted. All participants received usual care of approximately an hour of speech and language treatment, five to six days a week. Participants in the experimental condition received an additional hour-long CILT session, five days per week, for two weeks. Trained, untrained, and generalization probes comprising naming of pictured items and oral reading of sentences were taken at baseline, during treatment, and at post-treatment. All participants were probed equally. Probe performance was scored and effect sizes were calculated and compared. Performance gains from pre- to post-treatment on subtests of the Boston Diagnostic Aphasia Examination were also compared.

OUTCOMES AND RESULTS

Thirteen individuals with aphasia onset ranging from 7 to 68 days were recruited, with 6 allocated to the experimental Usual Care + CILT condition and 7 allocated to the control Usual Care condition. Increasing the amount of speech and language therapy by adding an hour of daily CILT was feasible. Individual performance varied within and across conditions with large gains noted in some, but not all participants. As a group, there was a small to medium effect size of the Usual Care + CILT condition over Usual Care alone for trained and untrained oral reading probes and untrained naming probes.

CONCLUSIONS

It is feasible to increase the amount of treatment provided to participants with aphasia on an acute inpatient rehabilitation unit. Preliminary results suggest that there may be better outcomes for those who receive more treatment. Further research using larger numbers of homogeneous participants and controlling for content of therapy as well as amount of therapy is warranted.

A Comparison of High and Low Dosages of a Component of Milieu Teaching Strategies for Two Preschool-Age Learners With Autism Spectrum Disorder

Purpose

The intersection of treatment intensity and communication intervention is an emerging area of investigation. Milieu teaching (MT) approaches for teaching communication skills to children with autism spectrum disorder (ASD) have a substantial evidence base (see Goldstein, 2002). However, a relatively small percentage (37.8%) of MT studies have fully detailed the parameters that are required to determine treatment intensity (Parker-McGowan et al., 2014). This study compared the effect of two dosages of the modeling component of milieu teaching on acquisition and maintenance of new vocabulary for two preschoolers with ASD.

Method

Low- and high-dosage conditions were compared within an adapted alternating treatments design. Participants were two preschool-age children with ASD.

Results

Results suggested a functional relationship between dose of MT models and acquisition of vocabulary items. For 1 participant, a high-dose application yielded more efficient acquisition. For the second participant, a low-dose application yielded more efficient acquisition.

Conclusion

The results of this study highlight the influence of individual differences in ostensibly similar persons and response to intervention. The need for better quantifying dosage parameters and examining the relationship between dosage and intervention approaches for preschool-age learners with ASD is discussed.

Structure, Processes, and Retrospective Outcomes From an Intensive Comprehensive Aphasia Program

PURPOSE

This study describes the structure, processes, and outcomes of an intensive comprehensive aphasia program (ICAP). The aim was to identify treatment gains and determine if outcomes were significantly different between participants grouped according to severity and type of aphasia, and time postonset.

METHOD

Data from 74 first-time ICAP participants were analyzed. Pre- and posttreatment scores on the Western Aphasia Battery-Revised and other impairment and participation measures were compared using paired t tests. Analyses of variance were used to compare outcomes related to aphasia severity (severe, moderate, and mild aphasia), aphasia type (fluent, nonfluent), and chronicity (0-6 months postonset, 7-12 months postonset, and 12+ months postonset).

RESULTS

Participants made significant changes on all impairment and participation measures. Large effect sizes were noted for one participation and three impairment measures. Medium effect sizes were noted for one impairment and three participation measures. There was no significant difference among groups on any factor.

CONCLUSION

ICAPs can have a significant effect on the language impairment and participation of people with aphasia, but further research is required to determine if the effect is comparable to other types of service delivery.

Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge

OBJECTIVE

To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI).

DESIGN

Prospective, longitudinal observational study.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge.

RESULTS

The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained.

CONCLUSIONS

At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.

Mapping speech pathology services to developmentally vulnerable and at-risk communities using the Australian Early Development Census

PURPOSE

The Australian Early Development Census (AEDC) is a population-based measure of children's development across five domains in the first year of formal schooling. In this study, the AEDC data from two domains (Language and Cognitive Skills and Communication Skills and General Knowledge) were used to explore the extent and distribution of vulnerability in communication skills among children in Australian communities. Speech Pathology Australia (SPA) membership data were then used to explore the accessibility of services within those communities.

METHOD

The 2012 AEDC data were accessed for 289,973 children, living in 577 communities across Australia. The number of children identified as "at risk" (10-25(th) percentile) or developmentally "vulnerable" (< 10(th) percentile) in each of the domains was calculated, then the location of communities with high proportions (> 20%) of these children was determined. These data were mapped against the location of paediatric speech-language pathologists (SLPs) to identify the number of communities with little to no access to speech-language pathology services.

RESULT

Across Australia, there were 47,636 children (17.4%) identified as developmentally vulnerable/at risk in Language and Cognitive Skills and 69,153 children (25.3%) in Communication Skills and General Knowledge. There were 27 communities with > 20% of children identified as developmentally vulnerable/at risk in Language and Cognition in their first year of formal schooling. Of those, none had access to speech-language pathology services, according to current SPA membership data. There were also 27 local government areas with > 20% of children identified as developmentally vulnerable/at risk in the Communication Skills and General Knowledge domain. Of these, three had access to SLP(s) and these were in regional/metropolitan areas.

CONCLUSION

The AEDC provides a means of identifying communities where children are performing well and communities which may benefit from population-based prevention or intervention. Given the number of communities within Australia without access to SLPs, there is a need to reconsider how such population-based services could be delivered, particularly in the communities with higher levels of vulnerability in communication development.

Early Intervention for Stuttering: Similarities and Differences Between Two Programs

In this paper, two proponents of different approaches to early stuttering discuss how they would manage a hypothetical case of stuttering in a preschool-age girl. Two evidence-based approaches are discussed: Palin Parent-Child Interaction Therapy and the Lidcombe Program. This paper arose from an oral discussion session held at the International Fluency Association Conference in Tours, France in 2012.

Treatment taxonomy for rehabilitation: past, present, and prospects

The idea of constructing a taxonomy of rehabilitation interventions has been around for quite some time, but other than small and mostly ad hoc efforts, not much progress has been made, in spite of articulate pleas by some well-respected clinician scholars. In this article, treatment taxonomies used in health care, and in rehabilitation specifically, are selectively reviewed, with a focus on the need to base a rehabilitation treatment taxonomy (RTT) on the "active ingredients" of treatments and their link to patient/client deficits/problems that are targeted in therapy. This is followed by a description of what we see as a fruitful approach to the development of an RTT that crosses disciplines, settings, and patient diagnoses, and a discussion of the potential uses in and benefits of a well-developed RTT for clinical service, research, education, and service administration.

Optimal intervention intensity

Empirical evidence exists for many of the different interventions in speech-language pathology. However, relatively little is known about the optimal intensity of those interventions. In order for speech-language pathology services to be both effective and efficient speech-language pathologists need to know how to faithfully administer ideal doses of the active ingredients of interventions, in what forms, how often and for how long. This is the lead paper to a scientific forum on this fundamental yet under-studied issue of clinical practice. Borrowing from the work of Warren, Fey, and Yoder, the concept of intervention intensity is described. Issues involved in establishing the optimal intensity of interventions are identified, including what and how intervention goals are targeted. Given that speech-language pathology interventions can involve the delivery of therapeutic inputs (e.g., conversational recasts, questions) and/or clients carrying out an act (e.g., speech production, voice production, comprehending, naming, swallowing), a framework is proposed for measuring all potential inputs and acts that might contribute to the calculation of an intervention intensity. Client-, clinician-, condition-, and service-related variables that could influence the investigation and practical application of an optimal intervention intensity are also discussed.