Practice Guidelines in Dysarthria: Supplemented Speech

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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

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Overview

• Introduction to Practice Guidelines
• Yorkston
• Supplemented Speech A Systematic Review
• Hanson
• Future Directions
• Beukelman

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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)
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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
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Improving Quality of Services

• Identify treatments strongly supported by
  evidence
• Prevention of unfounded practices
• The need to direct future research

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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

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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

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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

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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?
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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

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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
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Basis of Topic Selection

• Number of people affected
• High degree of variability in clinical practice
• Risk associated with practice
• Availability of scientific information

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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.

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Alphabet Supplementation Board
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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.

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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.

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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 its
  a noun, verb, adjective, etc. This type of
  supplementation is usually limited to research
  settings.

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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.

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Theoretic Foundation (Lindblom, 1990)

• High

Rich
High
Understandability
Non-speech Information
Low
High
Poor
Poor
Rich
Speech Signal Information
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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.)

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Search Results 19 studies
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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

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Search Results Medical Dx

• Cerebral palsy
• CVA
• TBI
• ALS
• Parkinsons disease

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Search Results Dysarthria Types

• Flaccid 63
• Spastic 26
• Mixed 32
• Athetoid 5
• Hypokinetic 5

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Search Results Supplementation Types

• Topic 6
• Alphabet 7
• Gesture 4
• Mixed 2

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Search Results Outcome Measures

• Intelligibility
• Speaking rate
• Comprehension
• Acoustic measures
• Phonetic transcription
• Listener attitudes
• Participation change

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Combined FindingsWord intelligibility for
Habitual Speech and Alphabet Supplementation

• Mean Gain 11.3

Word intelligibility
Severity Ranking
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Combined Findings Sentence Intelligibility for
Habitual Speech and Alphabet Supplementation

• Mean Gain 25.5

Sentence intelligibility
Severity Ranking
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Combined Findings Word Intelligibility for
Habitual Speech and Topic Supplementation

• Mean Gain 28.1

Word intelligibility
Severity Ranking
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Combined Findings Sentence Intelligibility for
Habitual Speech and Topic Supplementation

• Mean gain 10.7

Sentence intelligibility
Severity Ranking
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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.

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Limitations of interpretation

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

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What strategy is best?
Gestures

• Drawbacks
• appropriate gesture not available
• difficult to resolve breakdowns

• Benefits
• natural
• no external device
• may improve prosody

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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

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What strategy is best?
Topic (Semantic) Cues

• Benefits
• Intelligibility gains
• May have to only indicate once for several
  sentences

• Drawbacks
• appropriate category not available
• cognitive load
• external device required

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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.

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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

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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

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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

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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

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Questions
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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.

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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.