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:
To 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.
- 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
- 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
A throwaway remark by my Audiology lecturer caught me by surprise. She said that she sits behind children when training them after they receive a cochlear implant in order that they not rely on visual cues when learning to discriminate speech sounds.
Children and adults with hearing loss cannot simply be fitted with an aid or an implant and then walk away ready to hear. They need specific (and in some cases a lot of) training in perceiving speech sounds (as do hearing people, who do this as babies). However, there is a divide between deaf educators/audiologists about the best way to train listening in this population:
- Auditory-Verbal: No sign language, no visual-cues (i.e. lip-reading) – the child must learn to listen solely through the use of the acoustic signal.
- Auditory-Oral: Children can use lip-reading and contextual cues as well as listening to crack the speech signal.
Of course there are many shades between these two approaches, and countless other approaches to deaf education. Perhaps I’ll just link to the ASHA Evidence Map…
On the other side of the SP range of practice…
I thought it was interesting, because it conflicted with how we do phonological therapy in Speech Pathology, where children who cannot distinguish phonemes are encouraged to perceive both the articulatory and acoustic differences in the sounds. It also is a similar ‘debate’ in Aphasia rehabilitation. One approach is Constraint-Induced Language Therapy (CILT), where clients are restricted to verbal output (no gesture, writing or drawing) through the use of physical screens. A review  found large effect sizes, but since the therapy was intense, it remains unknown whether ‘constraint’ is an important aspect of the treatment.
However, there is another school of thought which claims clients should be able to draw on any residual communication in any form. Such an approach is found in Multi-Modal Aphasia Treatment (MMAT), which a pilot study found to be equally efficacious as CILT. A RCT is in the works.
The danger of single-treatment studies
When your study has only one treatment, even if it has a control, it is impossible to say whether it is a treatment that should be used. If clinicians are to choose the best treatments (which we are not presently required to do, all we are required to do is to use evidence-based treatments), we need more studies like  and less like . Two other examples spring to mind:
- Literacy: Is Reading Recovery more efficacious than a Systematic Phonics program?
- Fluency: Is Demands and Capacities Therapy more efficacious than the Lidcombe Program?
(There is research on the second question  finding equal efficacy, but the Lidcombe program was only administered for 12 weeks, in defiance of best-practice and proscribed standards for its implementation).
When we do therapy, we cannot point to research that proves that every component of the intervention (like constraint) is directly related to a result. Perhaps if we removed it, the treatment would still work. This is where a solid theoretical framework helps. If what I’m doing is reasonable given what I know about the body and the brain, I think I’m a lot more comfortable, even if a small aspect of my intervention hasn’t been checked by an RCT.
- Cherney, L. R., Patterson, J. P., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282–1299.
- Rose, M. L., Attard, M. C., et al. (2013). Multi-Modality Aphasia Therapy Is as Efficacious as a Constraint-Induced Aphasia Therapy for Chronic Aphasia: A Phase 1 Study. Aphasiology, 27(8), 938-971.
- Franken, M. C., Kielstra-Van der Schalk, C. J., Boelens H. (2005). Experimental treatment of early stuttering: a preliminary study. Journal of Fluency Disorders, 30(3), 189-99.