Evidence Evidence Evidence

Last week I had the immense privilege of attending a two-day workshop given by Dr Katherine Verdolini, covering her rather wordily named Lessac-Madsen Resonant Voice Therapy and Casper-Stone Confidential Flow Therapy (or LMRVT and CSCFT!). The programs are (I believe) proprietary, so I won’t talk about them too much.

However, Dr Verdolini did not limit the talk to the mechanics of voice therapy. She also talked at length about motor learning theory, patient compliance, and evidence-based practice. Her view was that while EBP is generally a good thing, the movement at present suffers from a number of flaws, which I’ll briefly summarise.

  • Systematic reviews of quality RCTs are considered the highest level of evidence, with clinical experience, available resources and patient preferences being consigned to the bottom of the ‘evidence pyramid’.
  • But RCTs will only tell you what will generally work for the ‘average’ patient, and these studies often exclude patients with complications – which are often the patients we see.
  • We develop a false sense of security with EBP that the research was external to the clinical reality it was measuring, when of course it took place within it.

I recall being in a clinic where I was working one-on-one with a ten-year-old boy with severe ASD. He was largely non-verbal, and we tried to convey the structure of his day to him through the use of a visual schedule. My clinic partner and I suggested supplementing the visual schedule with a ‘now/next’ board:

first+then+autism+5To keep our client oriented to the task, we would point to the board and say “Now we are doing X, then we will do Y” etc. I remember being surprised when my clinical educator asked if there was evidence regarding the use of such boards, in particular if there was evidence that colouring each space differently would be more effective.

I was a bit surprised. After all, it seemed obvious that it would, unless the client was colour-blind. What was absent from my CE’s comment was an exercise of clinical judgement – not every facet of our practice needs to be interrogated for its efficacy.

I believe what tends to happen is that EBP is used as a mallet to hit people on the head with. Evidence! Evidence! Evidence! Practicing clinicians are constantly told to integrate evidence into their practice, and for them, evidence is not clinical experience or consideration of patient preferences. Instead, they can have a narrow conception of EBP as being “that . . . double blinded, controlled thing.” (1). This conception probably comes from university courses which stress the evidence hierarchy, and actively ask students to challenge themselves if their thinking is ‘evidence-based’, which seems to be code for ‘I have read the systematic review’.

To put it simply, journal articles and other formal evidence is one piece of the puzzle for clinicians. If it were as simple as implementing a checklist from a guideline, SPs wouldn’t be counted as ‘professionals’ – we would be more like factory-workers. We add value from our ability to consider all issues: our resources, the patient’s/family’s preferences, the published evidence, and our experience in order to implement care.

In other news

One area which could probably do with more EBP is hydration in dysphagia management. I have talked about this before:

In the latest issue of IJSLP, I note a paper by a team from Curtin Uni (2), reporting that of all the factors considered by clinicians in bedside dysphagia assessment (such as oro-motor ability, oral hygiene, alertness, etc.), hydration status was considered the least, with less than 40% SPs surveyed reporting they usually or always consider hydration in their assessment.

This is worrying, considering the implications of dehydration, and the possible lack of coordination between dietetics and speech pathology regarding this issue.

However, more positively, I note that a student at JCU is investigating the impact of diet modifications on quality-of-life in dysphagic patients. I eagerly anticipate the results.

References

  1. Foster, A., Worrall, L., Rose, M., & O’Halloran, R. (2015). ‘That doesn’t translate’: the role of evidence-based practice in disempowering speech pathologists in acute aphasia management. Int J Lang Commun Disord. doi: 10.1111/1460-6984.12155
  2. Vogels, B., Cartwright, J., & Cocks, N. (2015). The bedside assessment practices of speech-language pathologists in adult dysphagia. Int J Speech Lang Pathol, 17(4), 390-400. doi: 10.3109/17549507.2014.979877
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