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Practice Guidelines in Dysarthria: Supplemented Speech

Practice Guidelines in Dysarthria: Supplemented Speech. Elizabeth K. Hanson, M.S., CCC-SLP Kathryn M. Yorkston, Ph.D., CCC-SLP David R. Beukelman, Ph.D., CCC-SLP. Overview. Introduction to Practice Guidelines Yorkston Supplemented Speech: A Systematic Review Hanson Future Directions

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Practice Guidelines in Dysarthria: Supplemented Speech

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  1. Practice Guidelines in Dysarthria: Supplemented Speech Elizabeth K. Hanson, M.S., CCC-SLP Kathryn M. Yorkston, Ph.D., CCC-SLP David R. Beukelman, Ph.D., CCC-SLP

  2. Overview • Introduction to Practice Guidelines • Yorkston • Supplemented Speech: A Systematic Review • Hanson • Future Directions • Beukelman

  3. Evidence-Based Practice • . . is a commitment to a constant reexamination of practices through research and outcomes analyses. - Enhancing our knowledge-base - Enhancing our decision making [Sackett et al., (1997)]

  4. Definition: Practice Guidelines • Clinical practice guidelines are explicit descriptions of how patients should be evaluated and treated. The explicit purpose of guidelines is to improve the quality of care and to assure it by reducing variation in care provided. - Review of evidence - Consensus of experts

  5. Improving Quality of Services • Identify treatments strongly supported by evidence • Prevention of unfounded practices • The need to direct future research

  6. Target Audiences Primary: the practicing SLP whose case load includes children & adults with dysarthria Secondary: • Consumers of rehabilitation services • Faculty and students in training • Funding agencies • Allied professionals

  7. Acknowledgment • Sponsored by the Academy of Neurologic Communication Disorders & Sciences (ANCDS) • With generous financial support from • ASHA - SID 2 • ASHA - VP for Clinical Practice in SLP • Department of Veterans Affairs

  8. Evidence-based practice guidelines for the management of dysarthria • Kathryn Yorkston, Chair • Kristie Spencer • David Beukelman • Joseph Duffy • Lee Ann Golper • Robert Miller • Edythe Strand • Marsha Sullivan

  9. From Evidence to Belief “Before evidence can influence your practice, it has to change your belief.” Rubenfeld, (2001), p. 1444 Are we dealing with horses or unicorns?

  10. Phases of Development: ANCDS Practice Guidelines • The Writing Committee • Developing the Questions • Searching the Literature • Rating Evidence • Report the Evidence • The Panel of Expert Reviewers • Dissemination of the Findings

  11. Clinic Focus Article Topics Lit. Review Draft Tech. Rpt Review Panel Final Tech. Rpt JMSLP 12/01 Resp/Phon: Clinical Decisions Velopharyngeal 12/03 SD: Med. Tx Resp/Phon: Systematic Rev 6/03 6/03 Speech Supplementation Submitted Improve Intelligibility Naturalness 6/04

  12. Basis of Topic Selection • Number of people affected • High degree of variability in clinical practice • Risk associated with practice • Availability of scientific information

  13. What is Supplemented Speech? • 1) Alphabet supplementation is a strategy in which the speaker provides orthographic information to listeners by identifying the first letter of each word (on an alphabet board or a forward-facing screen) just prior to each spoken word.

  14. Alphabet Supplementation Board

  15. What is Supplemented Speech? • 2) Semantic or topic supplementation is a strategy in which the topic of a message or a series of messages is provided to listeners just before the message(s) is spoken. The traditional form of topic context is a cue word or phrase that provides information about the intended meaning of an utterance or the intent of the speaker.

  16. What is Supplemented Speech? • 3) Gestures may be produced concurrently with speech. Also know as illustrators, these movements are directly tied to speech and serve to represent visually what is spoken verbally. See Garcia and Cannito (1996) for a review.

  17. What is Supplemented Speech? • 4) Syntactic supplementation is a strategy in which the speaker indicates syntactic information about the word being spoken, such as whether it’s a noun, verb, adjective, etc. This type of supplementation is usually limited to research settings.

  18. Rationale for review of Supplemented Speech • Primary goal of intervention: increase intelligibility • 1. Change acoustic signal • 2. Change context • Context: “the knowledge shared by communication partners about the time, place, topic, purpose, or any other feature of an utterance or the setting in which the utterance occurs. …including semantic, syntactic, suprasegmental, and pragmatic cues.”

  19. Theoretic Foundation (Lindblom, 1990) High Rich High Understandability Non-speech Information Low High Poor Poor Rich Speech Signal Information

  20. Systematic Review of Speech Supplementation • Databases: PsychINFO, CINAHL, MEDLINE • Search terms: “dysarthria” “supplement*” “first letter” “intelligibility” • Relevant chapters • Limited to research (not overviews, summaries, etc.)

  21. Search Results: 19 studies

  22. Search Results: Participants • # speakers: 80, mostly adults, age range 9-87 years • # listeners: 537, undergraduate and graduate students, some rehabilitation professionals or SLPs, some familiar vs unfamiliar partners

  23. Search Results: Medical Dx • Cerebral palsy • CVA • TBI • ALS • Parkinson’s disease

  24. Search Results: Dysarthria Types • Flaccid 63% • Spastic 26% • Mixed 32% • Athetoid 5% • Hypokinetic 5%

  25. Search Results: Supplementation Types • Topic 6 • Alphabet 7 • Gesture 4 • Mixed 2

  26. Search Results: Outcome Measures • Intelligibility • Speaking rate • Comprehension • Acoustic measures • Phonetic transcription • Listener attitudes • Participation change

  27. Combined Findings:Word intelligibility for Habitual Speechand Alphabet Supplementation Mean Gain = 11.3% Word intelligibility Severity Ranking

  28. Combined Findings: Sentence Intelligibility for Habitual Speech and Alphabet Supplementation Mean Gain = 25.5% Sentence intelligibility Severity Ranking

  29. Combined Findings:Word Intelligibility for Habitual Speech and Topic Supplementation Mean Gain 28.1% Word intelligibility Severity Ranking

  30. Combined Findings:Sentence Intelligibility for Habitual Speech and Topic Supplementation Mean gain = 10.7% Sentence intelligibility Severity Ranking

  31. How Much Change Expected? Average gain of 25% in sentence intelligibility with range from 5 to 70% How large must gain be to be functionally important? It depends on severity. 20% intelligibility gain may be minimal at 10% habitual but major at 60 or 70% habitual.

  32. Limitations of interpretation • Speech not spontaneous • None experienced with supplementation • No live, real-time dyads • Superimposed vs. speaker-imposed supplementation

  33. What strategy is best? Benefits natural no external device may improve prosody Gestures Drawbacks • appropriate gesture not available • difficult to resolve breakdowns

  34. What strategy is best? Alphabet Cues Benefits • intelligibility gains • used with any utterance • minimal learning • slows speaking rate • resolving breakdowns easy Drawbacks • listeners must accept & support • decreases naturalness • slows speaking rate • may disrupt prosody • requires external devices • cognitive and literacy requirements

  35. What strategy is best? Benefits Intelligibility gains May have to only indicate once for several sentences Topic (Semantic) Cues Drawbacks • appropriate category not available • cognitive load • external device required

  36. Benefits of Supplementation Strategies Speakers with severe - moderate dysarthria benefit most. Speakers with profound dysarthria benefit least (unless speaking rate control contributes to severity). Speakers with word boundary “problems” benefit from inter-word pauses that accompany alphabet supplementation. Speakers with mild dysarthria benefit least--may be useful in adverse communication situations.

  37. Future: Need to study supplemented speech in more natural communication contexts • Most previous supplemented speech research has been completed in controlled research settings. There is also a need to study it in a range of natural contexts and investigate: • 1. Use patterns • 2. Acceptance by various combinations of speaker and listener types. • 3. Effectiveness across contexts

  38. Future: Need to study learning demands of supplemented strategies • At this point the literature is relatively silent on the learning demands of the various types of supplemented speech by a range of different speakers. • Similarly, we know little about learning demands for listeners: • Children • Elderly • Cognitive disabilities • Limited educational backgrounds • ESL

  39. Future: Need to develop ways to predict cognitive/linguistic/social demands of SS • Development of predictive measures regarding: • 1. Ability to learn SS • 2. Willingness to use SS • 3. Listener acceptance of SS • 4. Amount and type of instruction needed

  40. Future: Need to include a range of listeners in outcome projects • Much of past research as used college students as listeners--often SLP students. Effectiveness as a listener Willingness to be a listener by social context

  41. Questions

  42. Publications Duffy, J. R., & Yorkston, K. M. (in press). Medical interventions for spasmodic dysphonia and some related conditions: A systematic review. Journal of Medical Speech-Language Pathology, 11(4). Hanson, E. K., Yorkston, K. M., & Beukelman, D. R. (submitted). Speech supplementation techniques for dysarthria: A systematic review. Journal of Medical Speech-Language Pathology. Rubenfeld, G. D. (2001). Understanding why we agree on the evidence but disagree on the medicine. Respiratory Care, 46(12), 1442-1449. Sackett, D. L., Richardons, W. S., Rosenberg, W., & Haynes, R. B. (1997). Evidence-based medicine. New York: Churchill Livingstone. Spencer, K. A., Yorkston, K. M., & Duffy, J. R. (2003). Behavioral management of respiratory/phonatory dysfunction from dysarthria: A flowchart for guidance in clinical decision-making. Journal of Medical Speech-Language Pathology, 11(2), xxxix-ixi.

  43. Practice Guideline Publications Yorkston, K. M., Spencer, K. A., & Duffy, J. R. (2003). Behavioral management of respiratory/phonatory dysfunction from dysarthria: A systematic review of the evidence. Journal of Medical Speech-Language Pathology, 11(2), xiii-xxxviii. Yorkston, K. M., Spencer, K. A., Duffy, J. R., Beukelman, D. R., Golper, L. A., Miller, R. M., Strand, E. A., & Sullivan, M. (2001). Evidence-based medicine and practice guidelines: Application to the field of Speech-Language Pathology. Journal of Medical Speech-Language Pathology, 9(4), 243-256. Yorkston, K. M., Spencer, K. A., Duffy, J. R., Beukelman, D. R., Golper, L. A., Miller, R. M., Strand, E. A., & Sullivan, M. (2001). Evidence-Based Practice Guidelines for Dysarthria: Management of Velopharyngeal Function. Journal of Medical Speech-Language Pathology, 9(4), 257-273.

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