Clinical Assessment of Communication-Related Speech Parameters in Dysarthria: The Impact of Perceptual Adaptation.

PURPOSE: In current clinical practice, intelligibility of dysarthric speech is commonly assessed by speech-language therapists (SLTs), in most cases by the therapist caring for the patient being diagnosed. Since SLTs are familiar with dysarthria in general and with the speech of the individual patient to be assessed in particular, they have an adaptation advantage in understanding the patient's utterances. We examined whether and how listeners' assessments of communication-related speech parameters vary as a function of their familiarity with dysarthria in general and with the diagnosed patients in particular. METHOD: Intelligibility, speech naturalness, and perceived listener effort were assessed in 20 persons with dysarthria (PWD). Patients' speech samples were judged by the individual treating therapists, five dysarthria experts who were unfamiliar with the patients, and crowdsourced naïve listeners. Adaptation effects were analyzed using (a) linear mixed models of overall scoring levels, (b) regression models of severity dependence, (c) network analyses of between-listener and between-parameter relationships, and (d) measures of intra- and interobserver consistency. RESULTS: Significant advantages of dysarthria experts over laypeople were found in all parameters. An overall advantage of the treating therapists over nonfamiliar experts was only seen in listening effort. Severity-dependent adaptation effects occurred in all parameters. The therapists' responses were heterogeneous and inconsistent with those of the unfamiliar experts and the naïve listeners. CONCLUSIONS: The way SLTs evaluate communication-relevant speech parameters of the PWD whom they care for is influenced not only by adaptation benefits but also by therapeutic biases. This finding weakens the validity of assessments of communication-relevant speech parameters by the treating therapists themselves and encourages the development and use of alternative methods.

Speech Versus Speaking: The Experiences of People With Parkinson's Disease and Implications for Intervention.

PURPOSE: In this project, we explore the experiences of people who report speech changes associated with Parkinson's disease as they describe taking part in everyday communication situations and report impressions related to speech treatment. METHOD: Twenty-four community-dwelling adults with Parkinson's disease took part in face-to-face, semistructured interviews. Qualitative research methods were used to code and develop themes related to the interviews. RESULTS: Two major themes emerged. The first, called "speaking," included several subthemes: thinking about speaking, weighing value versus effort, feelings associated with speaking, the environmental context of speaking, and the impact of Parkinson's disease on speaking. The second theme involved "treatment experiences" and included subthemes: choosing not to have treatment, the clinician, drills and exercise, and suggestions for change. CONCLUSIONS: From the perspective of participants with Parkinson's disease, speaking is an activity requiring both physical and cognitive effort that takes place in a social context. Although many report positive experiences with speech treatment, some reported dissatisfaction with speech drills and exercises and a lack of focus on the social aspects of communication. Suggestions for improvement include increased focus on the cognitive demands of speaking and on the psychosocial aspects of communication.

Management of non-progressive dysarthria: practice patterns of speech and language therapists in the Republic of Ireland.

BACKGROUND: Dysarthria is a commonly acquired speech disorder. Rising numbers of people surviving stroke and traumatic brain injury (TBI) mean the numbers of people with non-progressive dysarthria are likely to increase, with increased challenges for speech and language therapists (SLTs), service providers and key stakeholders. The evidence base for assessment and intervention approaches with this population remains limited with clinical guidelines relying largely on clinical experience, expert opinion and limited research. Furthermore, there is currently little evidence on the practice behaviours of SLTs available. AIMS: To investigate whether SLTs in the Republic of Ireland (ROI) vary in how they assess and manage adults with non-progressive dysarthria; to explore SLTs' use of the theoretical principles that influence therapeutic approaches; to identify challenges perceived by SLTs when working with adults with non-progressive dysarthria; and to determine SLTs' perceptions of further training needs. METHODS & PROCEDURES: A 33-item survey questionnaire was devised and disseminated electronically via SurveyMonkey to SLTs working with non-progressive dysarthria in the ROI. SLTs were identified through e-mail lists for special-interest groups, SLT manager groups and general SLT mailing lists. A reminder e-mail was sent to all SLTs 3 weeks later following the initial e-mail containing the survey link. The survey remained open for 6 weeks. Questionnaire responses were analysed using descriptive statistics. Qualitative comments to open-ended questions were analysed through thematic analysis. OUTCOMES & RESULTS: Eighty SLTs responded to the survey. Sixty-seven of these completed the survey in full. SLTs provided both quantitative and qualitative data regarding their assessment and management practices in this area. Practice varied depending on the context of the SLT service, experience of SLTs and the resources available to them. Not all SLTs used principles such as motor programming or neural plasticity to direct clinical work and some requested further direction in this area. SLTs perceived that the key challenges associated with working in this area were the compliance, insight and motivation of adults with dysarthria. CONCLUSIONS & IMPLICATIONS: The use of specific treatment programmes varies amongst SLTs. A lack of resources is reported to restrict practice in both assessment and management. Ongoing research into the effectiveness of SLT interventions with adults with non-progressive dysarthria is required to guide clinical decision-making. SLTs identified further training needs which may provide direction for the development of professional training courses in the future.

Speech pathologists' current practice with cognitive-communication assessment during post-traumatic amnesia: a survey.

PRIMARY OBJECTIVE: To investigate speech pathologists' current practice with adults who are in post-traumatic amnesia (PTA). METHOD: Speech pathologists with experience of adults in PTA were invited to take part in an online survey through Australian professional email/internet-based interest groups. RESULTS: Forty-five speech pathologists responded to the online survey. The majority of respondents (78%) reported using informal, observational assessment methods commencing at initial contact with people in PTA or when patients' level of alertness allowed and initiating formal assessment on emergence from PTA. Seven respondents (19%) reported undertaking no assessment during PTA. Clinicians described using a range of techniques to monitor cognitive-communication during PTA, including static, dynamic, functional and impairment-based methods. CONCLUSIONS: The study confirmed that speech pathologists have a key role in the multidisciplinary team caring for the person in PTA, especially with family education and facilitating interactions with the rehabilitation team and family. Decision-making around timing and means of assessment of cognitive-communication during PTA appeared primarily reliant on speech pathologists' professional experience and the culture of their workplace. The findings support the need for further research into the nature of cognitive-communication disorder and resolution over this period.

Survey of UK speech and language therapists' assessment and treatment practices for people with progressive dysarthria.

BACKGROUND: Dysarthria knowledge is predominantly impairment-based. As a result, speech and language therapists (SLTs) have traditionally adopted impairment-focused management practices. However, guidance for best practice suggests that SLTs should consider the client holistically, including the impact of dysarthria beyond the impairment. AIMS: To investigate the current assessment and treatment practices used by UK SLTs with clients with progressive dysarthria and to identify whether these satisfy the needs of SLTs in their everyday practice. To investigate the extent to which they consider oromotor abilities, intelligibility, functional communication, participation and interaction to be important regarding assessment and treatment decisions. To explore whether management decisions are affected by level of clinical experience or settings in which SLTs work. METHODS & PROCEDURES: An online survey of UK SLTs working with adults with progressive dysarthria. OUTCOMES & RESULTS: A total of 119 SLTs completed the survey. Respondents considered that targeting the levels of impairment, activity and participation are important in the management of clients with progressive dysarthria, as recommended by clinical guidelines and recent research. However a particularly high proportion of respondents reported the use of impairment-based assessments. Respondents reported lacking the necessary tools to target interaction in assessment and intervention. The intervention that respondents use with clients varies according to the progressive disorder and dysarthria severity. There is evidence for a trend that less experienced SLTs and those working predominantly in hospital-based settings focus on the impairment, whereas more SLTs with more experience and those based in predominantly community-based settings look beyond the impairment. CONCLUSIONS & IMPLICATIONS: The values held by SLTs match guideline recommendations for best practice, however the clinical reality is that the assessment of progressive dysarthria remains predominantly impairment-focused. New tools need to be developed and integrated into practice to target interaction in assessment and intervention, to reduce the gap between best practice recommendations and clinical reality. Ongoing research into the effectiveness of SLT intervention with clients with progressive dysarthria is required to guide clinical management decisions.

Clinical effectiveness, cost-effectiveness and service users' perceptions of early, well-resourced communication therapy following a stroke: a randomised controlled trial (the ACT NoW Study).

OBJECTIVE: To determine the clinical effectiveness, cost-effectiveness and service users' views of enhanced early communication therapy by speech and language (SL) therapists compared with attention control (AC). DESIGN: Successful feasibility study followed by a randomised trial with economic evaluation, and nested qualitative study using 32 individual interviews. SETTING: Twelve English NHS hospital and community stroke services. PARTICIPANTS: One hundred and seventy adults with aphasia or dysarthria admitted to hospital with stroke, December 2006 to January 2010. Eligibility determined by NHS SL therapists. Seventeen people declined follow-up. INTERVENTIONS: A best-practice, flexible intervention by NHS SL therapists, up to three contacts per week for up to 16 weeks compared with a similar number of AC contacts by employed visitors. MAIN OUTCOME MEASURES: Primary outcome was blinded, functional communicative ability 6 months post randomisation on the Therapy Outcome Measure activity subscale (TOM). Secondary outcomes were participants' perceptions on the Communication Outcomes After Stroke scale (COAST); carers' perceptions of participants from part of the Carer COAST; carer well-being on Carers of Older People in Europe Index and quality-of-life items from Carer COAST. Serious adverse events (SAEs) were recorded. Economic evaluation: participants' utility (European Quality of Life-5 Dimensions), service use and cost data from medical records and carers, and a discrete choice experiment. RESULTS: Intervention typically started after 2 weeks, providing 22 contacts. Both groups improved on the TOM. The estimated 6 months' group difference [95% confidence interval (CI)] was 0.25 (-0.19 to 0.69) points in favour of SL therapy. Sensitivity analyses adjusting for baseline chance imbalance or not imputing values for decedents further reduced this difference. Per-protocol analyses rejected a possible dilution of therapy from controls refusing allocation and receiving NHS SL therapy. There was no evidence of added benefit of therapy on any secondary outcome measure or SAEs, although the latter were less frequent in the therapy group [odds ratio 0.42 (95% CI 0.16 to 1.1)]. Regardless of group allocation, interviewed participants reported positive impacts on their confidence and mood, identified drivers for change and valued early and sustained contact. Health economic analysis indicated a high level of uncertainty. Early enhanced SL therapy for communication is likely to be cost-effective only if decision-makers are prepared to pay ≥ £25,000 to gain one unit of utility. CONCLUSIONS: These findings exclude the possibility of a clinically significant difference of 0.5 points on the TOM. There was no evidence, on any measure, of added benefit of early communication therapy beyond that from AC. It is unclear whether therapy is more or less cost-effective than AC. Early, frequent contact was highly valued by users and had good uptake. Functional communication improved for both groups, plausibly due to natural recovery and early and regular opportunity to practise everyday communication with a professional (therapist/visitor). There is no evidence to recommend enhancing the provision of early communication therapy by a qualified SL therapist over and above usual care. SL therapy service reorganisation should consider skill mix and timing within a stepped care model and should take place within the context of a trial.

An instrument for the multiparameter assessment of speech.

This paper describes the development of SNORS+, a clinical, user-friendly instrument for measurement of the articulators during speech. The design criteria for the instrument were based upon a wide-ranging review of current practice and available techniques. SNORS+ allows objective assessment of the function and co-ordination of key articulators. Appropriate targeting of therapy is therefore possible. Visual feedback is provided, for therapy, and an objective measurement of outcome is easily obtained. Preliminary results are presented. These suggest that the instrument will prove extremely useful in the assessment and management of many speech disorders.

Functional outcome assessment in dysarthria.

Strategies for the functional assessment of communication disorders experienced by persons with dysarthria can be based on the Chronic Disabilities Model described by Nagi (1991), which considers a disorders at five different levels, ranging from pathophysiology at the level of the tissue to the societal levels of dysfunction. Outcomes can be measured at all levels of the model. For example, at the pathophysiologic level, outcomes may indicate events at the tissue level during the course of the disease, whereas, at the level of the disability, outcomes reveal the adequacy of speech production using compensatory strategies in communicative contexts, and at the societal level, they may indicate the overall degree of success a speaker has in specific real-world speaking situations. This article focuses on "functional" assessment of persons with dysarthria. Thus, assessment is viewed from the perspective of how speech and the use of speech can be measured in functional situations over time or as a result of treatment.