Catherine Mackenzie’s research while affiliated with University of Strathclyde and other places

Background: There has been little robust evaluation of the outcome of speech and language therapy (SLT) intervention for post-stroke dysarthria. Non-speech oro-motor exercises (NSOMExs) are a common component of dysarthria intervention. A feasibility study was designed and executed, with participants randomized into two groups, in one of which NSOMExs were a component of the intervention programme. Aims: To examine (1) operational feasibility of the programme; (2) participants' views of the programme; and (3) speech intelligibility, communication effectiveness and tongue and lip movement at four points (A1 and A2 before, and A3 and A4 after intervention). Methods & procedures: Thirty-nine participants were randomized into Group A (n=20) and Group B (n=19). Groups were equivalent at enrolment in demographic variables and A1 measures. Intervention was behavioural, delivered in eight home-based SLT sessions, and included practise of individually appropriate words, sentences and conversation, and for Group B also NSOMExs. Between-session practice was recorded in a diary. Data on speech intelligibility, effectiveness of communication in conversation, self-rated situational communication effectiveness, and tongue and lip movement were collected at 8-week intervals, twice before and twice after intervention. Anonymous evaluation (AE) questionnaires were completed. Outcome & results: The recruited number was 20% below the target of 50. Thirty-six participants completed the intervention and 32 were followed through to A4. The programme was delivered to protocol and fidelity was verified. Thirty-four AEs were returned. These showed high satisfaction with the programme and its outcome. According to diary records from 32 participants, 59% carried out at least the recommended practice amount. Outcome measure performance across the four assessment points did not indicate any group effect. For the whole sample both externally rated and self-rated communication effectiveness measures showed statistically significant gains across the intervention period (A2/A3), which were maintained for 2 months after intervention (A2/A4). Non-intervention period changes (A1/A2 and A3/A4) were not present. There were no intervention-related gains in tongue and lip movement or speech intelligibility, but the latter is likely to be attributable to a ceiling effect on scores. Conclusions & implications: The results indicate positive outcomes associated with a short period of behavioural SLT intervention in the post-stroke dysarthria population. The inclusion of NSOMExs, delivered in accordance with standard clinical practice, did not appear to influence outcomes. The results must be viewed in relation to the nature of feasibility study and provide a foundation for suitably powered trials.

The Living with Dysarthria group programme, devised for people with post-stroke dysarthia and family members, was piloted twice. Feedback from those who experience an intervention contributes to the evaluation of speech and language therapy programmes, giving the participant view of the intervention's value and guiding further developments. What feedback do participants in the Living with Dysarthria programme provide, informing on its perceived usefulness and guiding its future development? Nine people with chronic dysarthria following stroke and four family members who completed the Living with Dysarthria programme all contributed to Focus Group (FG) discussion, transcribed and thematically analysed, and completed an Anonymous Questionnaire Evaluation (AQE), comprising closed statements and open questions. An anonymous descriptive adjective selection task (ADAST) was also used. The varied forms of feedback provided complementary information. Thematic analysis of FG data and AQE open question responses were configured around programme benefits, programme structure and content, and programme practicalities. Benefits associated with participation included learning and insight, being supported by peers and professionals, and improved speech and confidence. These are consistent with the main programme elements of education, support and speech practice. All activities were seen as relevant and positively received. Flexibility, recognition of and catering to individual needs were valued characteristics. The community location was approved by all. Most participants thought the format of eight weekly sessions of 2 h was appropriate. Responses to AQE closed statements provided almost unanimous confirmation of the very positive feedback conveyed in FG discussions. The main response to suggested improvements in AQEs was that the number of sessions should be increased. Feedback indicated that for a few individuals there was negative reaction to some facts about stroke, home practice tasks were difficult to complete, the person with dysarthria/family member pair may not be the optimum combination for paired practice activities and pre-programme information should be extended. The ADAST showed that the programme was enjoyable, interesting, stimulating and useful. Participant feedback indicates that group therapy, with family member participation, is a valid form of management for chronic post-stroke dysarthria. Education, peer and professional support, and speech practice are confirmed as relevant programme components. Consistent majority opinions were communicated in different situations and via varied mediums. Some individuals expressed views relevant to their own needs, and these responses also inform future implementation of the Living with Dysarthria programme.

Background: The broad life implications of acquired dysarthria are recognized, but they have received little attention in stroke management. Reports of group therapy, which may be a suitable approach to intervention, are not available for stroke-related dysarthria. Aims: To examine the operational feasibility of and response to a new eight-session weekly group intervention programme, Living with Dysarthria, designed for people with chronic dysarthria following stroke and their main communication partners. Methods & Procedures: The target participation was for programme completion by two groups of eight people with dysarthria (PWD) and available family members (FMs) or carers. An active recruitment strategy was undertaken from the speech and language therapy case records for the previous 6 years in two hospitals with combined annual stroke admissions of over 500 people. Twelve PWD and seven FMs were recruited (group 1: seven PWD and four FMs; group 2: five PWD and three FMs). Speech intelligibility, communication effectiveness, general well-being, quality of communication life, and knowledge of stroke and dysarthria were assessed pre- and post-programme. Each PWD and FM also set an individual goal and rated their achievement of this on a 0–10 scale. Outcomes & Results: Recruitment to the programme was lower than anticipated and below target. The 12 PWD were recruited from 62 initial contacts, which was the total number who according to available information met the criteria. The programme was viable: it ran to plan, with only minor content alterations, in community accommodation, and with good participant engagement. Group median score changes were in a positive direction for all measures and effect sizes ranged from 0.17 (quality of communication life) to 0.46 (intelligibility). Significant post-programme changes were present for intelligibility and knowledge of stroke and dysarthria (p= 0.05). Participants’ ratings of goal achievements ranged from 6 (some change) to 10 (a lot of change). Conclusions & Implications: The recruitment experience revealed a take-up rate of around 20% from PWD following stroke, informing future planning. The participant engagement and performance results from the piloting of the programme indicate that the Living with Dysarthria programme is viable and has potential for effecting positive change. Further testing is justified.

There is little published intervention outcome literature concerning dysarthria acquired from stroke. Single case studies have potential for more detailed specification and interpretation than is generally possible in larger studies so are informative for clinicians dealing with similar cases. Such research also contributes to planning of larger scale investigations. Behavioural intervention is described which was carried out between 7-9 months after stroke with a 69-year-old man with severe dysarthria. Pre-intervention stability between 5-7 months contrasted with post-intervention gains. Significant improvement was demonstrated using randomized, blinded assessment by 10 judges on measures of word and reading intelligibility and communication effectiveness in conversation. A range of speech analyses were undertaken (rate, pause, and intonation characteristics in connected speech and single word phonetic transcription), with the aim of identifying speech components which might explain the listeners' perceptions of improvement. Changes were detected mainly in parameters related to utterance segmentation and intonation. The basis of post-intervention improvement in dysarthria is complex, both in terms of the active therapeutic dimensions and also the specific speech alterations which account for changes to intelligibility and effectiveness.

Dysarthria is a frequent and persisting sequel to stroke and arises from varied lesion locations. Although the presence of dysarthria is well documented, for stroke there are scant data on presentation and intervention outcome. A literature search was undertaken to evaluate (a) the features of dysarthria in adult stroke populations relative to the conventional Mayo system for classification, which was developed from diverse pathological groups, and (b) the current status of evidence for the effectiveness of intervention in dysarthria caused by stroke. A narrative review of results is presented. The limited data available indicate that, regardless of stroke location, imprecise articulation and slow speaking rate are consistent features, and voice disturbances, especially harshness, and reduced prosodic variation are also common. Dysarthria is more prevalent in left than in right hemisphere lesions. There is a need for comprehensive, thorough analysis of dysarthria features, involving larger populations, with stroke and other variables controlled and with appropriate age-referenced control data. There is low level evidence for benefits arising from intervention in stroke-related dysarthria. Because studies involve few participants, without external control, and sometimes include stroke with other aetiologies, their results lack the required weight for confident evidence-based practice.

People with communication impairments may face barriers to civic participation, with resulting marginalisation of individuals who wish to be actively involved. The investigation aimed to explore the experience of civically engaged adults with acquired neurological communication difficulties. Six people with acquired neurological communication difficulties were interviewed. Discussion included the definition of active citizenship, their civic involvement, motivations, related barriers and facilitators. Qualitative analysis was undertaken, with data categorised, coded and examined for recurring themes. All participants were active in disability-related organisations and four undertook wider civic roles. Motivations included activity being out with the home and wanting to effect change for themselves and the populations they represented. Disability group meetings were more positive experiences than broader community activities, which were associated with fatigue and frustration, commonly resulting from communication difficulties and unmet support needs. All participants identified a need for professional and public educational about disability and communication and made recommendations on content, methods and priority groups. For these participants civic engagement had positive and negative dimensions. Speech and language therapists should promote reduction of the barriers that impede the active citizenship rights of people with communication support needs. Civic participation may be a relevant measure of outcome in communication impaired populations.

Non-speech oro-motor exercises (NSOMExs) are described in speech and language therapy manuals and are thought to be much used in acquired dysarthria intervention, though there is no robust evidence of an influence on speech outcome. Opinions differ as to whether, and for which dysarthria presentations, NSOMExs are appropriate. The investigation sought to collect development-phase data, in accordance with the Medical Research Council (MRC) evaluation of complex interventions. The aims were to establish the extent of use of NSOMExs in acquired disorders, the exercise regimes in use for dysarthria, with which dysarthric populations, and the anticipated clinical outcomes. A further aim was to determine the influencing rationales where NSOMExs were or were not used in dysarthria intervention. Speech and language therapists throughout Scotland, Wales, and Northern Ireland, working with adult-acquired dysarthria, were identified by their service heads. They received postal questionnaires comprising 21 closed and two open questions, covering respondent biographics, use of NSOMExs, anticipated clinical outcomes, and practice influencing rationales. One hundred and ninety-one (56% response) completed questionnaires were returned. Eighty-one per cent of respondents used NSOMExs in dysarthria. There was no association with years of speech and language therapy experience. Those who used and those who did not use NSOMExs provided similar influencing rationales, including evidence from their own practice, and Higher Education Institute teaching. More experienced speech and language therapists were more likely than those more recently qualified to be guided by results from their own practice. Input from the attended Higher Education Institute was more influential for those less experienced than for those more experienced. Clinical outcome aims were not confined to speech, but also included improvements in movement, sensory awareness, appearance, emotional status, dysphagia and drooling. NSOMExs were used with many neurological disorders, especially stroke, all dysarthria classes, especially flaccid, and all severity levels. Tongue and lip exercises were more frequent than face, jaw and soft palate. The most common regimes were four to six repetitions of each exercise, during three practice periods daily, each of 6–10 min. NSOMExs are a frequent component of dysarthria management in the UK-devolved government countries. This confirmation, along with the details of speech and language therapy practice, provides a foundation for clinical research which will compare outcomes for people with dysarthria, whose management includes and does not include NSOMExs. Speech and language therapy practice may be guided by evidence that speech outcome is or is not affected by NSOMExs.

Multiple sclerosis is a disabling neurological disease with varied symptoms, including dysarthria and cognitive and linguistic impairments. Association between dysarthria and cognitive-linguistic deficit has not been explored in clinical multiple sclerosis studies. In patients with chronic progressive multiple sclerosis, the study aimed to investigate the presence and nature of cognitive-linguistic deficit, the association between levels of cognitive-linguistic ability and speech intelligibility, and of both of these with functional disability and time since onset of multiple sclerosis symptoms. The Arizona Battery for Communication Disorders of Dementia (ABCD) (Bayles and Tomoeda 1993 ), The Assessment of Intelligibility of Dysarthric Speech (AIDS) Sentence Intelligibility Task (Yorkston and Beukelman 1984 ), and the Modified Barthel Activities of Daily Living Index (MBADLI) (Shah 1998 ) were administered to 24 chronic progressive multiple sclerosis participants with dysarthria. A total of 24 non-neurologically impaired participants, matched for gender, age and education, formed a control group. For multiple sclerosis participants, linear regression analysis showed a strong association between ABCD and AIDS (beta = 0.89, p = 0.005), no association between ABCD and either MBADLI or time since onset, a strong association between AIDS and MBADLI (beta = 0.60, p = 0.001), and a trend towards an association between AIDS and time since onset (beta = -0.29, p = 0.08). Correlations between the four included ABCD construct scores and between these and the total ABCD score were significant (r>0.60, p<0.01). For each of the 15 included ABCD measures and for the four construct scores and the overall ABCD score, multiple sclerosis and control group performances were significantly different (p<0.01) and effect sizes were large (d>0.80). The results revealed a strong association between dysarthria, as measured by connected speech intelligibility testing, and cognitive-linguistic deficit, in people with chronic progressive-type multiple sclerosis. While some of the impairments that are associated with multiple sclerosis, including motor speech disorder, may influence performance on the ABCD, the data support the conclusion that marked cognitive-linguistic deficit is present in chronic progressive-type multiple sclerosis patients with dysarthria. Deterioration was global, rather than being indicative of a construct specific deficit, and encompassed language, both expression and comprehension. Episodic memory and linguistic expression were especially affected. Speech and language therapists who work with dysarthric patients with chronic progressive multiple sclerosis should monitor cognitive-linguistic impairment. An awareness of this might influence assessment, intervention and management, including the information and advice given to patients and their relatives.

Background: Discourse analysis as a clinical tool in speech and language therapy remains underused, at least partly because of the time-consuming nature of the process of transcription that currently precedes it. If transcription-less discourse analysis were valid and reliable, then there would be the clinical opportunity to use this method in order to describe a person's communication impairment (for example aphasia), to help plan therapy and to measure outcomes. Aims: This study aimed to address the potential of transcription-less discourse analysis as a valid and reliable procedure for the measurement of gesture use, topic use, turn taking, repair, conversational initiation, topic initiation, and concept use. Methods & Procedures: Ten individuals with aphasia were audio- and video-recorded participating in a number of discourse tasks from three different discourse genres (conversation, procedural, and picture description). With the same analytical frameworks, the resulting data were compared using transcription-based discourse analysis and a transcription-less method in which the analysis was made directly from the recordings. Outcomes & Results: Validity was measured by comparing transcription-based and transcription-less analyses. Overall the results from that comparison demonstrated the potential of the latter method - none of the measures gave significant differences between scores from the two methods. The main (non-significant) disparities related to some aspects of gesture use and repair. The inter-rater reliability of the transcription-less method was also acceptable in general. Reliability was measured by the intraclass correlation coefficient (ICC) for the continuous measurements: it was strongest for the gesture totals and varied among the attributes of turn taking and repair. For the categorical measures (topic and conversation initiation and concept analysis) the percentage agreement was very good. Conclusions: These results indicate the potential availability of a valid and reliable transcription-less approach to analysis that speech and language therapists can apply to analyse their clients' discourse.