Purpose Speech and other oral functions such as swallowing have been compared and contrasted with oral behaviors variously labeled quasispeech, paraspeech, speechlike, and nonspeech, all of which o...

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Nonspeech Oral Movements and Oral Motor Disorders: A Narrative Review

Background
Dysarthria is an acquired speech disorder following neurological injury that reduces intelligibility of speech due to weak, imprecise, slow and/or unco-ordinated muscle control. The impact of dysarthria goes beyond communication and affects psychosocial functioning. This is an update of a review previously published in 2005. The scope has been broadened to include additional interventions, and the title amended accordingly.

Objectives
To assess the effects of interventions to improve dysarthric speech following stroke and other non-progressive adult-acquired brain injury such as trauma, infection, tumour and surgery.

Search methods
We searched the Cochrane Stroke Group Trials Register (May 2016), CENTRAL (Cochrane Library 2016, Issue 4), MEDLINE, Embase, and CINAHL on 6 May 2016. We also searched Linguistics and Language Behavioral Abstracts (LLBA) (1976 to November 2016) and PsycINFO (1800 to September 2016). To identify further published, unpublished and ongoing trials, we searched major trials registers: WHO ICTRP, the ISRCTN registry, and ClinicalTrials.gov. We also handsearched the reference lists of relevant articles and contacted academic institutions and other researchers regarding other published, unpublished or ongoing trials. We did not impose any language restrictions.

Selection criteria
We selected randomised controlled trials (RCTs) comparing dysarthria interventions with 1) no intervention, 2) another intervention for dysarthria (this intervention may differ in methodology, timing of delivery, duration, frequency or theory), or 3) an attention control.

Data collection and analysis
Three review authors selected trials for inclusion, extracted data, and assessed risk of bias. We attempted to contact study authors for clarification and missing data as required. We calculated standardised mean difference (SMD) and 95% confidence interval (CI), using a random-effects model, and performed sensitivity analyses to assess the influence of methodological quality. We planned to conduct subgroup analyses for underlying clinical conditions.

Main results
We included five small trials that randomised a total of 234 participants. Two studies were assessed as low risk of bias; none of the included studies were adequately powered. Two studies used an attention control and three studies compared to an alternative intervention, which in all cases was one intervention versus usual care intervention. The searches we carried out did not find any trials comparing an intervention with no intervention. The searches did not find any trials of an intervention that compared variations in timing, dose, or intensity of treatment using the same intervention. Four studies included only people with stroke; one included mostly people with stroke, but also those with brain injury. Three studies delivered interventions in the first few months after stroke; two recruited people with chronic dysarthria. Three studies evaluated behavioural interventions, one investigated acupuncture and another transcranial magnetic stimulation. One study included people with dysarthria within a broader trial of people with impaired communication.

Our primary analysis of a persisting (three to nine months post-intervention) effect at the activity level of measurement found no evidence in favour of dysarthria intervention compared with any control (SMD 0.18, 95% CI -0.18 to 0.55; 3 trials, 116 participants, GRADE: low quality, I² = 0%). Findings from sensitivity analysis of studies at low risk of bias were similar, with a slightly wider confidence interval and low heterogeneity (SMD 0.21, 95% CI -0.30 to 0.73, I² = 32%; 2 trials, 92 participants, GRADE: low quality). Subgroup analysis results for stroke were similar to the primary analysis because few non-stroke participants had been recruited to trials (SMD 0.16, 95% CI -0.23 to 0.54, I² = 0%; 3 trials, 106 participants, GRADE: low quality).

Similar results emerged from most of the secondary analyses. There was no evidence of a persisting effect at the impairment (SMD 0.07, 95% CI -0.91 to 1.06, I² = 70%; 2 trials, 56 participants, GRADE: very low quality) or participation level (SMD -0.11, 95% CI -0.56 to 0.33, I² = 0%; 2 trials, 79 participants, GRADE: low quality) but substantial heterogeneity on the former. Analyses of immediate post-intervention outcomes provided no evidence of any short-term benefit on activity (SMD 0.29, 95% CI -0.07 to 0.66, I² = 0%; 3 trials, 117 participants, GRADE: very low quality); or participation (SMD -0.24, 95% CI -0.94 to 0.45; 1 study, 32 participants) levels of measurement.

There was a statistically significant effect favouring intervention at the immediate, impairment level of measurement (SMD 0.47, 95% CI 0.02 to 0.92, P = 0.04, I² = 0%; 4 trials, 99 participants, GRADE: very low quality) but only one of these four trials had a low risk of bias.

Authors' conclusions
We found no definitive, adequately powered RCTs of interventions for people with dysarthria. We found limited evidence to suggest there may be an immediate beneficial effect on impairment level measures; more, higher quality research is needed to confirm this finding.

Although we evaluated five studies, the benefits and risks of interventions remain unknown and the emerging evidence justifies the need for adequately powered clinical trials into this condition.

People with dysarthria after stroke or brain injury should continue to receive rehabilitation according to clinical guidelines.

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Interventions for dysarthria due to stroke and other adult-acquired, non-progressive brain injury

Purpose This article describes the effects of a new intensive dysarthria treatment program (Be Clear) on speech intelligibility in adults with dysarthria secondary to stroke and traumatic brain inj...

Be Clear: A New Intensive Speech Treatment for Adults With Nonprogressive 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.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1460-6984.2012.00183.x

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

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, wi...

Dysarthria in stroke: a narrative review of its description and the outcome of intervention.

Background: 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.Aims: 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.Methods & Procedures: Speech and language therapists throughout Scotland, Wales, and Northern Ireland, working with adult-acquired dysarthria, were identified by their service heads. They received postal q...

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Non-speech oro-motor exercise use in acquired dysarthria management: regimes and rationales

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. 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). 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.

Non‐speech oro‐motor exercises in post‐stroke dysarthria intervention: a randomized feasibility trial

In West Glasgow email has evolved from a rapid means of arranging therapy appointments with adults who stammer into a medium for exchange of therapeutic messages with some clients. Since 2004, sixteen clients have used email to communicate as part of their therapy programme. The benefits include improving access to services, supporting speech change, facilitating lasting personal growth, improving clinical decision-making, equalizing the therapist-client relationship and enhancing caseload management. Although this experience suggests that email is appropriate for stammering therapy, the effectiveness and ethics of, and the rationale for, clinical practice that includes email need careful consideration. Further research is required to formally evaluate the client experience.

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The use of email as a component of adult stammering therapy: a preliminary report.

Background: Client opinions are appropriate contributions to the design and evaluation of health care services. Adults who stammer (AWS) have previously informed discussion regarding speech and language therapy (SLT) services; however, contemporary UK perspectives are lacking. Aim: This study aimed to identify features of helpful and unhelpful SLT services for AWS from the client and potential user perspective. Highlighting preferred components of therapy from this standpoint can help to ensure that SLT services are client-centred. Methods: An online survey was conducted using questions largely derived from UK professional guidelines of minimum best practice. Responses were subjected to quantitative and qualitative analysis. Results: Both positive and negative aspects of individual and group therapy for AWS were identified. Ideal service characteristics related to ‘therapy and therapist’ and ‘service delivery’ issues. Results were generally consistent with previous similar studies. In addition, considerat...

Carolyn Allen

Papers

Non-speech oro-motor exercise use in acquired dysarthria management: regimes and rationales

Non‐speech oro‐motor exercises in post‐stroke dysarthria intervention: a randomized feasibility trial

The use of email as a component of adult stammering therapy: a preliminary report.

Perspectives on the past and the future: clients' views on UK service provision for adult stammering