INT J LANG COMMUN DISORD, MAY–JUNE 2015,

VOL. 50, NO. 3, 374–388

Research Report
Management of non-progressive dysarthria: practice patterns of speech
and language therapists in the Republic of Ireland
Aifric Conway and Margaret Walshe
Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
(Received February 2014; accepted September 2014)

Abstract
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 Survey-
Monkey 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.

Keywords: non-progressive dysarthria, speech and language therapy, survey, stroke, traumatic brain injury.

What this paper adds?

What is already known on this subject?
Practice patterns amongst SLTs vary. A range of factors including experience, resources, clinical guidelines and
the availability of evidence influences this. The evidence base for speech and language therapy assessment and
intervention in non-progressive dysarthria is limited. Clinical guidelines are dominated by expert opinion and small-
scale research studies. Research is predominantly impairment-based, while there has been an increasing interest in
holistic approaches to client management.

Address correspondence to: Aifric Conway, Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland;
e-mail: conwaya2@tcd.ie, Tel: +353 86 1508257
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online ⃝ C 2015 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12143
Survey of SLT practices: non-progressive dysarthria
What this study adds?
Understanding the practice patterns of SLTs is important as it provides a general picture of approaches to management
of client groups at a specific point in time, providing direction for research, training and practice.
Introduction
Non-progressive dysarthria is a motor speech disorder
resulting from non-progressive diseases of the central
nervous system such as stroke and traumatic brain in-
jury (TBI) (Sellars et al. 2005). About 20–30% of
people who have a stroke experience weakness, in-
coordination or paralysis of the muscles required to
produce speech (Warlow et al. 2001). Dysarthria oc-
curs in approximately one-third of people following TBI
(Murdoch and Theodoras 2001). Despite its frequency,
non-progressive dysarthria management tends to receive
less specific attention in the literature (Brady et al. 2011,
Dickson et al. 2008). The reason for this is unclear but
as Palmer and Enderby (2007) suggest, much of the
current research is focused on adults with progressive
dysarthria specifically that associated with Parkinson’s
disease (PD).
The distinction between non-progressive and pro-
gressive dysarthria is important as both follow distinctly
different care pathways but how speech and language
therapists (SLTs) routinely manage progressive and non-
progressive dysarthria remain unexplored. Examination
of practice patterns at a specific point in time is im-
portant for practising clinicians. It affords an opportu-
nity to examine the factors that influence the delivery
of services and forces reflection on ‘why we do what
we do’.
There is a significant and apparent gap in the litera-
ture regarding the views and practices of SLTs working
with this clinical population. It cannot be assumed that
the practices of SLTs in the assessment and management
of dysarthria will be the same as those in related areas
such as dysphagia (Bateman et al. 2007, Martino et al.
2004, Pettigrew and O’Toole 2007) and aphasia (Brum-
fitt 2006). Nor can it be presumed that practices for pro-
gressive dysarthria (Collis and Bloch 2012, Miller et al.
2011) will be the same as non-progressive dysarthria.
Coincidentally, Collis and Bloch (2012) published a
survey of United Kingdom (UK) SLT practice patterns
in the management of progressive dysarthria at the time
this current study was underway. This research allows
for comparison of SLT practice with non-progressive
dysarthria and to examine practice differences between
the UK and Republic of Ireland (ROI).
For both progressive and non-progressive dysarthria
the objective is to determine the presence, nature and
extent of impairment to assist in differential diagno-
sis with a view towards directing management. It also
involves defining the extent of its impact on activities
375
and participation as well as its effect on the individ-
ual’s psychosocial function and quality of life (Walshe
2011). With regard to assessment practices in progres-
sive dysarthria, Collis and Bloch (2012) found that tools
used predominantly by SLTs in the UK include the Fren-
chay Dysarthria Assessment (Enderby and Palmer 2008)
and the Dysarthria Profile (Robertson 1982). Both as-
sessments, while important for differential diagnosis,
remain impairment-focused despite an increasing in-
terest in participation and in the psychosocial impact of
dysarthria. Furthermore, Collis and Bloch (2012) found
a discrepancy between what assessments SLTs use, and
what they consider important in assessment. How SLTs
typically assess non-progressive dysarthria is unknown.
With regard to intervention approaches, with a
recommendation for SLTs to underpin treatment with
research evidence (Irish Association of Speech and
Language Therapists (IASLT) 2008) and despite the
long-standing involvement of SLTs treating dysarthria,
there is a distinct lack of robust evidence to support
popular SLT treatments (Mackenzie et al. 2010).
Mackenzie et al. (2010) surveyed SLTs regarding the use
of non-speech oral motor exercises (NSOMEs). They
found no relationship between treatment practices of
these SLTs and their belief of a supporting evidence
base. This suggests that a number of other factors are
directing clinical practice.
Lack of evidence may be one contributory factor.
This emphasizes the importance of examining how
SLTs are practising in the absence of research evidence.
Systematic reviews of interventions in dysarthria
(Palmer and Enderby 2007, Sellars et al. 2005) have
been unable to draw conclusions regarding the efficacy
of various treatment programmes for non-progressive
dysarthria, emphasizing the need for methodologically
sound research in the area. This gap in research
presents a recurring challenge in the implementation of
evidence-based practice (EBP) as there is little direction
provided for clinical work.
Therapeutic approaches should be underpinned by
theoretical principles. A number of researchers advocate
the application of principles of neural plasticity (Ludlow
et al. 2008) and motor learning (Maas et al. 2008) in
the treatment of acquired dysarthria. Although the use
of such principles to improve therapy outcomes has not
been rigorously tested, it is important that SLTs are
aware of emerging evidence in the field and any survey
of practice patterns should incorporate some exploration
of this area.
376
Lack of evidence to direct practice may not be
the only factor that influences practice patterns in
dysarthria. Clarification on the role of the SLT in
the management of non-progressive dysarthria may
be a further issue. The SLTs’ role in the assessment
and management of non-progressive dysarthria is well
established but remains broadly defined by professional
bodies and clinical guidelines (Royal College of Speech
and Language Therapists (RCSLT) 2006). For example
the RCSLT (2006: 251) states that the role of the SLT is
‘enabling an individual to achieve a mode of communi-
cation fitting to their age, gender, social circumstances
and desires, within the limitations dictated by their
neurological condition’. While the IASLT (2007: 6)
states that the practice of SLTs includes the ‘assessment,
diagnosis, habilitation and rehabilitation of individuals
presenting with communication and swallowing
disorders’.
The influence of clinical practice guidelines on SLT
practice patterns is unclear. Studies investigating the
practice patterns of SLTs in progressive dysarthria found
that management practices often do not match guide-
line recommendations either in methods of assessments,
or focus of intervention (Miller et al. 2011).
Models of intervention may be a further factor
that influence practice patterns. Biopsychosocial
frameworks such as the International Classification
of Functioning, Disability and Health (ICF) (World
Health Organisation (WHO) 2001), draw attention
to the multifactorial consequences of communication
disorders (Baylor et al. 2009). The components of
the ICF framework are reflected in the Irish and UK
clinical guidelines previously discussed (IASLT 2007,
RCSLT 2006). However, it is unclear if SLTs are using
all components of this framework in practice (Collis
and Bloch 2012). Therefore, information is required
from the assessment and intervention practices of
SLTs in accordance with the ICF. Training, clinical
experience and available resources are further factors hy-
pothesized to influence practice patterns in dysarthria.
This study is concerned with practice patterns of
SLTs in ROI, as this is where the authors are based.
There are almost 1200 SLTs registered with IASLT
in Ireland (personal communication, IASLT, 2013).
These SLTs come from a variety of backgrounds with
many receiving their professional qualifications outside
ROI.
The aims of this study are (1) to investigate how
SLTs in the ROI assess and manage adults with non-
progressive dysarthria; (2) to explore SLTs use of the the-
oretical principles that influence therapeutic approaches;
(3) to identify challenges perceived by SLTs when work-
ing with adults with non-progressive dysarthria; and
(4) to determine SLTs’ perceptions of further training
needs.
Aifric Conway and Margaret Walshe
Method
This study employed an online survey questionnaire.
Ethical approval was granted by the Health Sciences
Research Ethics Committee of Trinity College Dublin
(TCD).
Questionnaire
An online survey for SLTs was designed and piloted
specifically for this study. A survey method was cho-
sen as it can be used to obtain information from a
large number of SLTs and provide an overall picture
of the current factors in practice (Pring 2005). Non-
progressive dysarthria was defined as dysarthria result-
ing from non-progressive diseases of the central nervous
system acquired in adulthood (i.e. 18 plus years). Items
for the survey were generated through a review of the
literature, clinical guidelines in the area and available
evidence base.
The survey was piloted by the first author on two
SLTs working with acquired neurological communica-
tion disorders in the ROI. This was important to help
establish content, face and ecological validity of the sur-
vey. The survey was then revised after the pilot trial,
amending some statements that were ambiguous, thus
ensuring that the content of the final version was ap-
propriate and that the instructions for completion were
clear and explicit.
Core sections of the 33 item survey questionnaire
included: (1) demographic information; (2) assess-
ment practices in non-progressive dysarthria; and (3)
non-progressive dysarthria management practices (see
appendix A).
! Section A: This section sought information on the
profile of respondents and the context in which
SLT services are delivered. It required details on
respondents’ professional qualification in SLT,
country of completion of professional qualifying
course, current job setting, number of years prac-
tising as an SLT, portion of caseload spent working
with adults with non-progressive dysarthria, and
! Section B: SLT assessment routines were explored
waiting times in the public sector.
through questions on SLTs’ practices regarding a
variety of assessment tasks. These involved ques-
tions on completion of an oro-facial examination,
frequency of use of formal assessments, frequency
of assessment of the speech subsystems, utilization
of standard reading passages, use of instrumenta-
tion, assessment of activities and participation,
repetition of formal assessments, use of the Mayo
Clinic System (Darley et al. 1969) and descriptive
Survey of SLT practices: non-progressive dysarthria
comments regarding barriers to effective assess-
! Section C: Information was sought on SLT man-
ment.
agement practices in non-progressive dysarthria
specifically techniques and devices used to treat
each speech subsystem (e.g. the Lee Silverman
Voice Treatment (LSVTTM ), Continuous Posi-
tive Airway Pressure (CPAP), Expiratory Muscle
Strength Training (EMST) and other behavioural
techniques). The integration of principles of mo-
tor learning, motor feedback, and neural plasticity
into therapy programmes with this population
was also explored, as well as the utilization of
Alternative and Augmentative Communication
(AAC) devices. Descriptive comments regarding
perceived challenges in working with people with
non-progressive dysarthria were requested and
SLTs were also asked to identify further training
needs.
A range of question formats were used to elicit in-
formation in all sections of the survey. These included
closed multiple choice, matrix choice, and rating scale
questions. Free text boxes were also used where responses
could not be pre-classified or additional views were
sought (see appendix A).
Sample
Inclusion criteria for target participants were SLTs
working in the ROI with adults with acquired non-
progressive dysarthria with Internet access for survey
completion.
Data collection
The survey was uploaded on SurveyMonkeyTM
(http://www.SurveyMonkey.com) and made available to
SLTs between 15 October and 25 November 2012. Re-
spondents were given the option to leave the survey
and return at any point. Response sheets sought no
identifying information. Four gatekeepers were used for
the dissemination of the survey. The secretary in the
Department of Clinical Speech and Language Studies,
TCD circulated an e-mail on the researchers’ behalf to
SLTs on the department’s mailing list. This e-mail con-
tained information about the survey and a link to the
online survey. The chairpersons of the Special Inter-
est Group in Adult Acquired Communication Disor-
ders and Neurology Network also acted as gatekeepers
and disseminated the survey to all SLT members on
their mailing lists. The Dillman Total Design Method
(Dillman 2007) was modified and implemented in this
study by sending participants an e-mail inviting them to
377
participate in the study and a reminder e-mail 3 weeks
after the initial e-mail was sent.
Data processing and analysis
All responses to the surveys were stored directly in a
SurveyMonkeyTM database. An advantage of using on-
line surveys is that responses can be converted auto-
matically into a spreadsheet or database, which has the
twin benefits of speed and accuracy in terms of data
collection. The results of the survey were prepared for
analysis by collating frequency of responses to objec-
tive questions (e.g. work settings of respondents, years
of experience) or frequency of responses within descrip-
tive categories (e.g. barriers to assessment). The authors
carried out the analysis of qualitative comments manu-
ally. All qualitative comments for the relevant sections
were transferred to a Microsoft WordTM document. The
authors read the qualitative comments regarding indi-
vidual sections of the survey separately. Key themes were
identified from these comments. The authors agreed on
the emerging themes. Each comment was then coded
according to these specific themes. All comments were
accounted for and no data were discarded.
Results
Respondents
Eighty SLTs took part in the survey, and 67 (83.3%) of
these completed it in full. It is unclear how many people
received the survey as convenience sampling was used.
It is also unknown if a full geographical spread of re-
spondents was achieved as any identifying information
including the respondent’s geographical region was not
sought to protect respondent anonymity. The majority
(61.2%, n = 49) of respondents held an undergrad-
uate professional qualification in speech and language
therapy. Most (77.5%, n = 62) received their profes-
sional qualification in Ireland. The remainder received
their qualifications in the UK, Australia, United States,
Poland and South Africa.
The majority (72.5%, n = 45) worked in a public
(government funded) hospital. However, 22.5% (n =
18) of respondents chose not to identify their primary
workplace. Over two-thirds (66.3%, n = 53) of respon-
dents had been practising as an SLT for fewer than 10
years, with 23.7% (n = 19) practising for fewer than 20
years. Only 10% (n = 8) had been practising as an SLT
for greater than 20 years. Most (95.5%, n = 76) SLTs
worked for 20 hours or more per week, with 5% (n = 4)
working fewer than 20 hours per week. For the majority
(74.7%, n = 59), adults with non-progressive dysarthria
represented less than a quarter of their caseload.
378
Figure 1. Reported in-patient waiting times (n = 55).
Information was provided regarding waiting times
for SLT services for in-patients (figure 1) and out-
patients (figure 2).
ROI SLTs’ assessment practices for non-progressive
dysarthria
Sixty-one respondents (80.2%) said they were confi-
dent in their ability to assess non-progressive dysarthria.
However, 13.2% (n = 10) stated they were ‘not sure’
and 6.5% (n = 5) reported that they were not confident
in their assessment skills with this population.
Formal assessments
Over half (57.9%, n = 44) of respondents stated they
would routinely use formal assessments with this pop-
ulation and listed the assessments they used most fre-
quently (table 1), while 40.7% (n = 31) reported they
would not routinely use formal assessments with people
with non-progressive dysarthria.
Informal assessments
Sixty-six respondents (86.8%) reported they always
carry out an oro-facial examination with adults with
non-progressive dysarthria. No one reported that they
‘never’ completed an oro-facial examination. Almost
Aifric Conway and Margaret Walshe
two-thirds (64.4 %, n = 49) of SLTs reported ‘always
or usually’ using standardized reading passages in the
assessment of adults with non-progressive dysarthria.
Respondents provided information on how fre-
quently they assessed specific components of speech
production in adults with non-progressive dysarthria
(table 2). Articulation was always or usually assessed
while prosody was less frequently assessed.
SLTs then indicated how often they would assess
the activities and participation domains of the ICF
framework in adults with non-progressive dysarthria
(table 3). Psychosocial impact and environmental
barriers to communication were always or usually
assessed by up to 90% of respondents. Five of the
76 respondents reported that they never assessed
attitudinal barriers to communication.
The majority (85.1%, n = 63) reported that they
do not use video recording in assessment, while 5.4%
(n = 4) were ‘not sure’ and 9.4% (n = 7) reported that
they use video recording. However, 63.1% (n = 48)
reported that they routinely used audio recording as
part of assessment of this clinical population.
Over half (52%, n = 39) of respondents said they
‘sometimes’ carried out a repeat formal assessment in
order to have at least two assessment results on the per-
son with non-progressive dysarthria. A total of 9.3%
(n = 7) of respondents stated that repeat assessment was
Survey of SLT practices: non-progressive dysarthria 379

Figure 2. Reported out-patient waiting times (n = 52).

Table 1. Reported assessments utilized by respondents (n = 73)

Formal assessments Percentage Response count

Frenchay Dysarthria Assessment (Enderby 1983) 47.9% 35
Frenchay Dysarthria Assessment 2 (Enderby and Palmer 2008) 43.8% 32
Robertson Dysarthria Profile (Robertson 1982) 23.3% 17
Assessment of Intelligibility of Dysarthric Speech (Yorkston and Beukleman 1981) 54.8% 40
Sentence Intelligibility Test (Yorkston et al. 1996) 8.2% 6
The Quick Assessment for Dysarthria (Tanner and Culbertson 1999) 1.4% 1
The Drummond Dysarthria Examination Battery (Drummond 1993) 0.0% 0
Dysarthria Impact Profile (Walshe et al. 2009) 4.1% 3
Informal assessments 13.6% 10
Answered question 73
Skipped question 7

Table 2. Reported assessment of the components of speech production in adults with non-progressive dysarthria (n = 76)

Always or usually Sometimes Never Response count

Articulation 100% (76) 0.0% (0) 0.0% (0) 76
Phonation 98.6% (75) 1.3% (1) 0.0% (0) 76
Respiration 92.1% (70) 6.6% (5) 1.3% (1) 76
Resonance 88% (66) 10.7% (8) 1.3% (1) 75
Prosody 77.6% (59) 21.1% (16) 1.3% (1) 76
Answered question 76
Skipped question 4

‘not applicable’ to their clinical setting as ‘clients can
be discharged unexpectedly’ or ‘without prior warning’.
While, three (4%) respondents commented that this de-
pends on length of stay in the inpatient setting before
transferring to a rehabilitation unit.
There was a lack of consensus on whether assessment
practices differed between non-progressive and progres-
sive dysarthria. Less than half (43.4%, n = 33) of respon-
dents stated that they would not assess non-progressive
dysarthria differently to progressive dysarthria.
380
Table 3. Reported domains assessed in adults with non-progressive dysarthria (n = 76)
Always or usually
Communication effectiveness beyond the clinical setting
Environmental barriers to communication
Attitudinal barriers to communication
Depression/anxiety
Quality of life
Psychosocial impact of dysarthria
Answered question
Skipped question
However, 21.1% (n = 16) reported they were ‘not sure’
and 35.5% (n = 27) stated their assessment would differ
between populations.
There was a further lack of consensus on the use of
the Mayo Clinic System (Darley et al. 1969). Almost
half (45.3%, n = 34) of respondents reported that they
routinely used this classification system in describing dif-
ferent types of dysarthria while a similar number (44%,
n = 33) did not use it and 10.7% (n = 8) were unsure.
Instrumental assessment
Respondents indicated that they use instrumentation
infrequently in their assessment of adults with non-
progressive dysarthria (table 4).
Barriers to effective assessment
Forty-three respondents (53.8%) provided qualitative
information regarding the barriers that they perceived
existed that limit effective assessment of adults with
non-progressive dysarthria. Four key themes emerged:
lack of resources, limitations of proper assessment mea-
sures, professional limitations and the presence of co-
morbidities including dysphagia (table 5).
ROI SLTs’ intervention practices for non-progressive
dysarthria
When treating speech rate in this clinical population,
almost all (95.5%, n = 64) reported that they fre-
quently use pacing techniques (e.g. pacing boards ±
metronome), while no respondents used instrumenta-
tion (e.g. oscilloscope) in treatment (figure 3).
Approximately two-thirds (75.8%, n = 47) reported
‘always or usually’ using speech drills to work on res-
onance. However, 92.3% (n = 48) and 90% (n =
45) reported ‘never’ using See-ScapeTM and CPAP,
respectively.
In the management of articulation, the majority
(84.7%, n = 39) of respondents ‘always or usually’ use
traditional speech drills (i.e. articulation of vowels, con-
sonants, consonant clusters etc.) (table 6).
Almost all (95.9%, n = 46) reported ‘never’ using
instrumental approaches in the management of prosody,
Aifric Conway and Margaret Walshe
Sometimes Never Response count
84.2% (64) 11.8% (9) 4% (3) 76
90.7% (69) 6.5% (5) 2.8% (2) 76
68.4% (52) 25% (19) 6.6% (5) 76
69.7% (53) 27.6% (21) 2.7% (2) 76
88.1% (67) 10.6% (8) 1.3% (1) 76
90.6% (68) 8.1% (6) 1.3% (1) 75
76
4
with 88.7% ‘always or usually’ using traditional speech
drills. The majority of respondents (82.8%, n = 53)
‘always or usually’ use posture when treating respiration.
Over three –quarters of SLTs (77%, n = 47) reported
‘always or usually’ using non-speech tasks, such as di-
aphragmatic breathing to improve respiratory function.
In the treatment of phonation, the use of LSVTTM
was divided among respondents as 49.2% (n = 30)
reported ‘always or usually’ using it and 50.8% (n = 31)
reported ‘sometimes’ or ‘never’ using it (figure 4).
Respondents indicated that the most popular AAC
devices routinely used in cases of severe non-progressive
dysarthria where such devices are indicated (figure 5)
were Lightwriters⃝ R
(Toby Churchill, UK) and alpha-
bet boards. Over one-fifth of SLTs (22.7%, n = 15)
commented that ‘other’ devices included communica-
tion books and handwriting with selection of devices
influenced by constraints on the funding available for
devices.
Theoretical principles influencing practice
The majority (70.3%, n = 45) of SLTs agreed with the
statement that they ‘usually consider the principles of
motor learning when devising intervention strategies’.
However, when questioned further regarding these spe-
cific principles many SLTs responded ‘not sure’ and the
number of respondents choosing ‘agree’, ‘not sure’ and
‘disagree’ were very similar (table 7). Seven SLTs (10.6%)
commented that they were not familiar with the termi-
nology used in the questions.
Respondents provided information regarding the
provision of feedback given to the person with non-
progressive dysarthria throughout a session. The major-
ity (90.8%, n = 59) agreed that they would always let
the client know how they have performed on a task.
However, over one-fifth (21.9%, n = 14) did not be-
lieve that it was necessary to plan the structuring of
feedback in advance of a session. While 90.9% (n =
60) of respondents said they believe in the principles of
neural plasticity when working with adults with non-
progressive dysarthria, 56.9% (n = 37) of respondents
disagreed with the principle of neural specificity in treat-
ing adults with dysarthria.
Survey of SLT practices: non-progressive dysarthria 381
Table 4. Reported utilization of instrumentation in assessment (n = 75)

Always or usually Sometimes Never Response count

Computerized Speech Lab 1.4% (1) 10.8% (8) 87.8% (65) 74
Multi-speech system 0.0% (0) 1.4% (1) 98.6% (71) 72
Praat 0.0% (0) 2.8% (2) 97.2% (70) 72
Visi-speech 2.8% (2) 5.6% (4) 91.7% (66) 72
Visi-pitch 2.8% (2) 8.2% (6) 89% (65) 73
Sona Speech 0.0% (0) 1.4% (1) 98.6% (71) 72
Analysis of Dysphonia in Speech and Voice (ADSVTM ) 0.0% (0) 0.0% (0) 100% (72) 72
Electroglottograph (EGG) 0.0% (0) 0.0% (0) 100% (72) 72
The Voice Range Profile 0.0% (0) 2.8% (2) 97.2% (70) 72
The Multi-Dimensional Voice Program (MDVP) 1.5% (1) 7.4% (5) 91.2% (62) 68
Other (please specify) 8
Answered question 75
Skipped question 5

Table 5. Reported barriers to assessment in non-progressive dysarthria (n = 43)

Response count
Lack of resources (time, equipment, instrumentation) 65.1% (28)
Limitations of available assessments (subjective nature, poor validity and reliability, lack of psychosocial measures) 37.2% (16)
Professional limitations (training, caseload) 14% (6)
Co-morbidities/prioritization of dysphagia 16.3% (7)

Figure 3. Reported techniques and devices utilized to work on speech rate (n = 67).

Table 6. Reported techniques and devices utilized to work on articulation (n = 67)

Always Usually Sometimes Never Response count

Oromotor exercises 22.2% (10) 35.6% (16) 31.1% (14) 11.1% (5) 45
Traditional speech drills 52.2% (24) 32.6% (15) 15.2% (7) 0.0% (0) 46
Combination of both 40.3% (25) 37.1% (23) 17.7% (11) 4.8% (3) 62
Other (please specify) 12
Answered question 67
Skipped question 13

Challenges when working with adults with
non-progressive dysarthria and identified
training needs
SLTs described the challenges they perceive in working
with adults with non-progressive dysarthria. The themes
that emerged from the qualitative data provided by re-
spondents are shown in table 8.
Respondents then described the changes they would
make to their practices or changes that they de-
sired in working with this clinical population. The
following themes emerged from the qualitative data;
382
Figure 4. Reported techniques and device utilized to work on phonation (n = 65).
Figure 5. Utilization of AAC devices in cases of severe dysarthria (n = 66).
(1) increased access to resources (clinical time, instru-
mentation, video, audio and AAC equipment) (57.9%,
n = 22), (2) more time to work on functional commu-
nication (23.7%, n = 9), (3) more regular measurement
of treatment outcomes (21%, n = 8), and (4) increased
awareness of the evidence base available (7.9%, n = 3).
Discussion
This study reflects the thoughts, views and practices of
a group of SLTs working in the ROI, the majority of
whom had received their professional qualifications in
the discipline in recent years. SLTs who responded to the
survey delivered care in a range of settings; principally
public hospitals, rehabilitation facilities and community
care. While most clients, both inpatients and outpatients
were seen promptly, it was evident that in some instances
this population can wait long periods of time for care
in the Irish public healthcare system. It should be noted
that the Irish healthcare system is largely a government
funded public healthcare system and it is possible that
Aifric Conway and Margaret Walshe
adults with dysarthria may seek private treatment, al-
though this was not investigated in the current survey.
SLTs in ROI assessment of non-progressive dysarthria
The majority of SLTs used formal assessments, contrast-
ing practice in progressive dysarthria (Collis and Bloch
2012). Based on the information provided by respon-
dents, the most common formal assessments used were
the AIDS assessment (Yorkston and Beukleman 1981)
and the Frenchay Dysarthria Assessment (Enderby and
Palmer 2008). SLTs largely agreed that it is important to
assess aspects of communication beyond the impairment
and intelligibility paralleling findings in progressive
dysarthria (Collis and Bloch 2012, Miller et al. 2011),
and reflecting the limited range of assessments available.
Other similar findings to progressive dysarthria include
a high proportion of SLTs using oro-facial assessment
reflecting its importance in differential diagnosis of un-
derlying conditions associated with dysarthria. The use
of instrumentation in dysarthria assessment is included
Survey of SLT practices: non-progressive dysarthria 383
Table 7. Applications of the principles of motor learning (n = 66)

Agree Not sure Disagree Response count

I consider how I will organize practice trials during 81.5% (53) 15.4% (10) 3.1% (2) 65
drill work
I prefer to use a large rather than a small number of 46.9% (30) 23.4% (15) 29.7% (19) 64
practice trials
I prefer to use massed practice rather than distributed 30.2% (19) 52.4% (33) 17.4% (11) 63
practice
I generally use variable practice rather than constant 41.3% (26) 36.5% (23) 22.2% (14) 63
practice with the patient
I routinely use random practice rather than blocked 20.3% (12) 42.4% (25) 37.3% (22) 59
practice with the patient
Organization of practice trials is not important in 10.8% (7) 23% (15) 66.2% (43) 65
my therapy sessions that involve drill work
Answered question 66
Skipped question 14

Table 8. Perceived challenges in working with adults with non-progressive dysarthria (n = 54)

Response count
Lack of insight and motivation from clients (resistance, lack of progress) 57.9% (22)
Lack of resources (time, instrumentation, AAC) 44.7% (17)
Limited evidence base (lack of psychosocial measures) 26.3% (10)
Co-morbidities/impaired cognition 13.2% (5)

in clinical guidelines (IASLT 2007, RCSLT 2005). The
strikingly low levels of SLTs that reported using instru-
mentation in assessment supports findings in progressive
dysarthria (Collis and Bloch 2012).
Attention to intelligibility of speech was evident in
this group with the majority of respondents reporting
that the AIDS assessment (Yorkston and Beukleman
1981) was most frequently used and many used stan-
dardized reading passages. This contrasts with Miller
et al.’s (2011) study examining the practice patterns of
SLTs in the UK in which the majority of respondents
neglected this domain in assessment in PD.
Recent research documenting the psychosocial im-
pact of dysarthria and its effect on communicative par-
ticipation (Dickson et al. 2008, Walshe and Miller 2011)
may have led to higher levels of awareness among SLTs
with many reporting assessment of these domains. This
supports findings in progressive dysarthria (Collis and
Bloch 2012, Miller et al. 2011). When asked regard-
ing barriers to effective assessment with this group, re-
spondents commented on the scarcity of assessments
available examining social and psychological impact, a
recognized obstacle in the field (Miller et al. 2011).
Environmental barriers were assessed by a significant
proportion of SLTs, again despite the fact that there are
no comprehensive formal assessments for examining this
area in any systematic way and quality of life measures
were consistently included in assessment by the majority
of respondents. This contrasts practice in progressive
dysarthria as Miller et al. (2011) found that few SLTs
included quality of life scales in adults with PD.
Treatment techniques varied, possibly due to the lit-
tle available evidence supporting the efficacy of one treat-
ment over another (Sellars et al. 2005). SLTs surveyed
showed an appreciation of the need to intervene in do-
mains beyond the impairment of dysarthria, consistent
with practice in progressive dysarthria (Collis and Bloch
2012, Miller et al. 2011). Consistent also with findings
in progressive dysarthria (Collis and Bloch 2012, Miller
et al. 2011), there are inadequate resources available to
SLTs for managing this group in a holistic manner. Al-
most a quarter of those surveyed complained of a lack
of clinical time to work on functional communication
and training family members although respondents ac-
knowledged its importance.
Principles governing SLT practice
It has been proposed that ‘where there is a lack of pub-
lished evidence to guide practice, therapists are likely
to adopt differing regimes’ (Mackenzie et al. 2010: 627)
and the survey findings here suggest variation in practice
regimes.
High numbers of SLTs in the ROI reported that they
used NSOMEs, either in isolation or combined with
traditional speech drills, in the treatment of articula-
tion. These are surprising findings given there is limited
empirical evidence regarding their efficacy (McCauley
et al. 2009) and the evidence supporting their use in this
384
clinical population (Robertson 2001) has been weak.
These results support somewhat findings from surveys in
the UK (Dean and Heron 2010, Mackenzie et al. 2010).
However, the percentages of SLTs using NSOMEs ap-
pear to be higher in these earlier studies; perhaps suggest-
ing that with time, the use of NSOMEs is diminishing
or perhaps that simply the methodological differences
in obtaining survey information played a part in these
small discrepancies. SLTs may use NSOMEs for many
reasons, perhaps due to tradition, or client and carer
expectations (Mackenzie et al. 2010). Regardless of the
rationale for their use, Duffy (2007) rates the resolu-
tion of this debate as a research priority due to ongoing
confusion among clinicians.
LSVTTM (Sapir et al. 2008) has strong support for
its efficacy in the treatment of voice and articulation in
progressive dysarthria. Recently, LSVTTM has been pro-
posed as a viable option for adults with non-progressive
dysarthria (Wenke et al. 2011). However, researchers
have not come to any clear conclusions on whether
LSVTTM is more advantageous than traditional treat-
ment techniques (Wenke et al. 2011). Nevertheless,
many respondents believed LSVTTM to be a valuable
method for the treatment of all subsystems with the ex-
ception of resonance; albeit there was variability among
SLTs regarding its use in these subsystems. Moreover, it
is worth noting that when questioned regarding chal-
lenges in practice, 45% of SLTs in this survey indicated
a lack of time available to implement intense therapy.
Therefore, it appears the delivery of LSVTTM would be
difficult in its precisely prescribed form due to service
delivery issues, supporting Miller et al.’s (2011) findings
in progressive dysarthria.
No SLTs surveyed used instrumentation in the treat-
ment of speech rate despite evidence of its efficiency in
slowing speech rate and increasing intelligibility (Palmer
and Enderby 2007). This requires further investigation.
The survey also explored an awareness and use of
principles suggested in the literature to influence out-
comes in dysarthria therapy. For example, Maas et al.
(2008) propose some preliminary evidence suggesting
that the principles of motor learning may be valid in
the treatment of the dysarthrias. Although the evidence
is not strong, it is important that SLTs are aware of
emerging evidence in the field. SLTs responding to the
survey were cognisant of these principles. However, a
number indicated some confusion regarding the termi-
nology and applications of principles, specifically with
reference to feedback and organization of practice drills.
Ludlow et al. (2008) have suggested applying the
principles of neural plasticity into speech motor control
rehabilitation. However, there is uncertainty regarding
the limits of neural plasticity following TBI, and these
limits need to be determined for speech (Ludlow et al.
Aifric Conway and Margaret Walshe
2008). Therefore, it was not surprising that many SLTs
were confused regarding the application of these princi-
ples to dysarthria rehabilitation.
Challenges when working with adults with
non-progressive dysarthria and SLT training needs
Eighty percent of respondents were confident in their
ability to assess non-progressive dysarthria. However,
SLTs identified a number of challenges in the field. Re-
spondents voiced the lack of suitable assessments and
outcome measures and many commented on the scarcity
of assessments that met their clinical needs. These re-
sults corroborate Collis and Bloch’s (2012) study with
a consensus on the lack of confidence in the tools avail-
able for assessing dysarthria regardless of whether it is
progressive or not. Many of these assessments are dated
(30 plus years) and may not reflect recent emergences
regarding the multifactorial impact of dysarthria on the
individual, beyond the level of impairment (Walshe and
Miller 2011).
A further challenge mentioned was the signifi-
cant lack of instrumentation and technical equipment
available in the clinical setting, leading to restric-
tions in both assessment and treatment. However, it
must be noted that some software, for example Praat
(http://praat.en.softonic.com), can be downloaded free
of charge. This might suggest a need for further edu-
cation and awareness of the use of software and instru-
mentation and, many SLTs did identify this as a further
training need. For intervention, it is not surprising that
instrumentation or tools least used from a list given (see
appendix A) were those with either little evidence to sup-
port their use (See-ScapeTM ) or with limited availability
to SLTs (CPAP). SLTs described video and audio record-
ing as lacking and unavailable, although their use is rec-
ommended in clinical guidelines (IASLT 2007, RCSLT
2005). Furthermore, although the provision of AAC
devices is included in clinical guidelines (IASLT 2007,
RCSLT 2009), almost one-quarter commented on the
lack of funding available for high-technology AAC
devices, thereby reducing the communication options
available to those with severe communication needs.
Respondents suggested a lack of clinical time as a
barrier to the effective assessment and management of
this group underpinning the findings of Collis and Bloch
(2012). The prioritization of dysphagia was perceived
to be a barrier to effective management. Further in-
vestigation would be required to establish other factors
underlying perceived time pressures; however these may
include high workloads, large caseloads and competing
role demands (Collis and Bloch 2012).
Surprisingly, 58% of SLTs considered a lack of in-
sight and motivation from the client to be the biggest
Survey of SLT practices: non-progressive dysarthria
challenge to management. The findings of Brady et al.
(2011) and Dickson et al. (2008) would suggest that
people with non-progressive dysarthria are acutely aware
of their difficulties; however this may not be directly
linked to motivation. This view has been supported by
the findings of Mackenzie et al. (2010) and Robertson
(2001) in which client compliance was determined to
be an issue in delivering treatment programmes.
Limitations of the study
A survey methodology is limited in that it comprises spe-
cific questions or statements (Collis and Bloch 2012).
SLTs may be ‘forced’ to choose inappropriate pre-coded
answers that might not fully represent their views. Ques-
tions were optional and therefore, not all respondents
answered all questions. This can introduce bias if non-
respondents differ in some way from respondents. Fur-
thermore, questions including ‘traditional speech drills’
and ‘vocal exercises’ might have been ambiguous. Per-
haps respondents did not understand the exact meaning
of certain questions, or they did not feel strongly about
the topic.
It is worth noting that the survey may not have
reached all SLTs working with this clinical population
in the ROI. The electronic format created a bias in
that it eliminated potential respondents who were not
‘on-line’. It is clear from the number of rejected e-mail
addresses that some of the database information of the
TCD Department was out of date. It is possible that
more SLTs would have responded if the survey were open
for longer. Also, it only became apparent towards the
conclusion of the study that the survey was not posted
on the IASLT website, due to a miscommunication,
thereby reducing the number of SLTs to whom it was
made available.
There is currently no census to quantify the num-
ber of SLTs working with adults with non-progressive
dysarthria in the ROI (IASLT Professional Development
Manager, personal communication, December 2012).
Therefore, there is no certainty regarding the repre-
sentativeness of this study’s sample. Furthermore, the
geographical spread of respondents across the ROI is
unknown. These limitations of the study are acknowl-
edged. Nonetheless a high number of responses, repre-
senting a wide range of experience and work settings,
were received making the contribution of the current
study noteworthy and significant in the field.
Implications of the study findings
Respondents’ comments highlight ongoing challenges
facing clinicians and provide directions for future pro-
fessional development courses. Efforts need to be di-
rected towards providing more and varied opportunities
385
for advanced learning experiences in order to ensure an
adequately trained clinician workforce in the ROI. Fur-
thermore, SLTs require more definitive guidelines from
professional organizations and national bodies to ensure
a greater awareness of the breadth and depth of the SLT
role in stroke and TBI, both among SLTs and referring
agents.
Consistent with practice in other clinical popula-
tions, variability exists among SLTs in the assessment and
management of non-progressive dysarthria. Although
one may expect a certain degree of variability based on
professional biases, it is vital to ensure that clinicians are
practising according to prevailing standards.
Cited within a wider international context, this
study is consistent with findings in the United States
regarding dysphagia (Mathers-Schmidt and Kurlinski
2003), Australia regarding tracheostomy (Ward et al.
2008) and the UK regarding progressive dysarthria
(Collis and Bloch 2012) indicating that clinician dis-
agreement in the profession of speech and language
therapy is an international concern.
Conclusions
This study has provided an insight into the practices and
views of SLTs working with adults with non-progressive
dysarthria in the ROI. The results of this survey sup-
port a clear need for the development of measures and
interventions to address aspects of communication be-
yond the level of impairment and intelligibility, adding
further to the call for resources in this area (Collis and
Bloch 2012, Walshe and Miller 2011).
Comparisons and contrasts with progressive
dysarthria populations are possible indicating that as-
sessments and interventions are used on both popula-
tions regardless of the different patterns of progression
and disease outcome. The identification of further train-
ing needs may provide direction for the development of
professional development courses in future.
Acknowledgements
Declaration of interest: The authors report no conflicts of interest.
The authors alone are responsible for the content and writing of this
paper.
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Survey of SLT practices: non-progressive dysarthria
Appendix A: Summary of information elicited in
the survey
Section A: Demographic Information
Section B: Assessment Practices
387
1. What is your professional qualification in SLT? (Undergraduate, Postgraduate)
2. What is your highest level of qualification in SLT? (Bachelor degree, Postgraduate
diploma, M.Sc/M.A, PhD)
3. Where did you complete your professional qualifying course? [Ireland, UK, USA,
Canada, Australia, New Zealand, Other (please specify)]
4. What is your current job setting? (Tick all that apply) [Public hospital, Private
hospital, Facility for intellectual disability, Rehabilitation facility, Private practice,
Other (please specify)]
5. How many years have you been practising as an SLT? (Less than 1 year, Less than 5
years, Less than 10 years, Less than 15 years, Less than 20 years, Greater than 20
years)
6. How many hours per week do you work as an SLT? (Less than 20 hours, 20 hours or
more)
7. What portion of your current caseload is spent working with people with non -
progressive dysarthria? (Less than or about 25%, Less than or about 50%, Less than or
about 75%, Greater than 75%)
8. What are the current waiting times (if any) for out-patients in your service? (free
text box)
9. What are the current waiting times (if any) for in-patients in your service? (free text
box)
10. How often do you perform an orofacial examination on people with
non-progressive dysarthria? (Never, Some of the time, Most of the time, Always,
Comment)
11. What formal assessments do you use with people with non-progressive dysarthria
(tick all that apply)? [Frenchay Dysarthria Assessment (Enderby 1983), Frenchay
Dysarthria Assessment 2 (Palmer & Enderby 2008), Robertson Dysarthria Profile
(Robinson 1982), Assessment of Intelligibility of Dysarthric Speech ( Yorkston &
Beukelman 1981), Sentence Intelligibility Test ( Yorkston, Beukelman & Tice 1996),
The Quick Assessment for Dysarthria ( Tanner & Culbertson 1999), The Drummond
Dysarthria Examination Battery ( Drummond 1993), Other (please specify)]
12. Which components of speech production do you assess in people with dysarthria?
(Always, Usually, Sometimes, Never)
[Respiration, Prosody, Resonance, Articulation, Phonation]
13. Do you use standardised reading passages in your assessment of people with
non-progressive dysarthria? (Always, usually, sometimes, never, Comment)
14. Do you use any of the following instrumentation in your assessment of people
with non-progressive dysarthria? (Always, usually, sometimes, never)
[Computerised Speech Lab, Multi-speech system, Praat, Visi-speech, Visi-pitch, Sona
Speech, Analysis of Dysphonia in Speech and Voice (ADSVTM ), Electroglottograph
(EGG), The Voice Range Profile, The Multi-Dimensional Voice Program (MDVP),
Other (please specify)]
15. Do you assess the following domains in people with non-progressive dysarthria
(please tick all that apply)? (Always, usually, sometimes, never) [Communication
effectiveness beyond the clinical setting, Environmental barriers to communication,
Attitudinal barriers to communication, Depression/anxiety, Quality of Life, Psychosocial
impact of dysarthria]
16. Do you routinely carry out repeat formal assessments on this population so that
you have at least two assessment results on the client? (Always, usually, sometimes,
never, Comment)
17. Please state your level of agreement with the following statements. (Strongly agree,
Agree, Not sure, Disagree, Strongly disagree)
[I assess people with dysarthria differently to people with non-progressive dysarthria, I do
not routinely use a formal assessment with this population, I routinely use the Mayo
Classification System in describing the type of dysarthria, I do not routinely use audio
recording as part of my dysarthria assessment, I do not routinely use video recording as
part of my dysarthria assessment, I am confident in my ability to accurately assess people
with non-progressive dysarthria, Comment]
388
Section C: Management Practices
Aifric Conway and Margaret Walshe
18. Please feel free to give make comments on any aspect of assessment with people
with non-progressive dysarthria. (free text box)
19. What do you see as the greatest barrier to effective assessment of people with
non-progressive dysarthria? (free text box)
20. If you need to work on the client’s SPEECH RATE, which one of the following
techniques would you use most frequently? (Always, Usually, Sometimes, Never)
[Alphabet board, Instrumental equipment (e,g oscilloscope), Pacing techniques (pacing
board, metronome etc), Cued meter strategy (e.g underlining written words etc),
Computer presenting words at altered rates, Other (please specify)]
21. If you need to work on the client’s RESONANCE, which one of the following
techniques and devices would you use? (Always, Usually, Sometimes, Never)
[Continuous Positive Airway Pressure (CPAP), Prosthetic devices ( e.g Palatal lift/palatal
training appliance), Speech drills, See-Scape, Nasometer, Other (please specify)]
22. If you need to work on the client’s ARTICULATION, which one of the following
techniques and devices would you use? (Always, Usually, Sometimes, Never)
[Oromotor exercises, Traditional speech drills, Combination of both, Other (please specify)]
23. If you need to work on the client’s PROSODY, which one of the following
techniques and devices would you use? (Always, Usually, Sometimes, Never)
[Traditional speech drills, Instrumental approaches (Multi-Speech, CSL etc.), Lee Siverman
Voice Programme, Other (please specify)]
24. If you need to work on the client’s PHONATION, which one of the following
techniques and devices would you use? (Always, Usually, Sometimes, Never)
[Physiological approaches (vocal cord adduction, respiratory muscle strength training,
breathing patterns etc.), Vocal exercises, Lee Silverman Voice Treatment, Other (please
specify)]
25. If you need to work on the client’s RESPIRATION, which one of the following
techniques and devices would you use? (Always, Usually, Sometimes, Never)
[Inspiratory muscle strength training, Expiratory muscle strength training, Non speech tasks
(diaphragmatic breathing etc), Posture, Prosthesis, Speech exercises focusing on
controlling airflow, Other (please specify)]
26. I usually consider the principles of motor learning when I am devising my
intervention strategies. [Yes, Not sure, No, Comment]
27. Please state whether you agree or disagree with the following statements. (Strongly
agree, Agree, Not sure, Disagree, Strongly disagree)
[I consider how I will organise practice trials during drill work in a session, I prefer to use a
large rather than a small number of practice trials during a session, I prefer to use massed
practice rather than distributed practice during a session, I generally use variable practice
rather than constant practice with the patient, I routinely use random practice rather
than blocked practice with the patient, Organisation of practice trials is not important in
my therapy sessions that involve drill work, Other (please specify)]
28. Please state whether you agree or disagree with the following statements. (Strongly
agree, Agree, Not sure, Disagree, Strongly disagree)
[When giving feedback to clients I always let them know how they have performed on tasks,
When giving feedback to clients I always let them know how the results at the end of a
task, I consider the frequency of feedback when I am devising a speech programme, I vary
my feedback according to the client and his/her psychological needs rather than the task, I
do not believe that it is necessary to consider how you structure your feedback in advance
of a session, Other (please specify)]
29. Please indicate whether you agree or disagree with the following statements:
(Strongly agree, Agree, Not sure, Disagree, Strongly disagree)
[If intervention does not work directly on speech, speech will not improve, Speech training
items or oromotor exercises need to be repeated several times in order to achieve change,
Simple repetitive tongue movements do not enhance skilled movements involved in
articulation, I believe in the principles of neural plasticity when working with clients
with dysarthria]
30. In cases of severe dysarthria where AAC is needed, which devices do you routinely
use with this population? [IPad apps, IPhone apps E-Tran Frame, Lightwriter,
Alphabet board, DynaVox Technologies, Other (please specify)]
31. What are the challenges that you find in working with people with non-progressive
dysarthria? (free text box)
32. If you had to make one change to how you work with people with non-progressive
dysarthria, what would it be? (free text box)
33. If you feel you have any additional training needs in the area, can you identify
these? (free text box)