Rodney Gabel, Ph.D., CCC-SLP, BRS-FD

A new fad that jumped up out of nowhere Only a research issue Something to be afraid of

Standard definition from Sackett, Rosenberg, Gray, Haynes and Richardson (1996)◦ Evidence based medicine is “….the conscientious,

explicit, and judicious use of current best evidence in making decisions about the care of individual patients….by integrating individual clinical expertise with the best available external clinical evidence from systematic research (p. 71).”

The definition was updated by the same authors in 2000 to include patient values:◦ ….the integration of best available research

evidence, expertise, and patient values. ◦ A combination of internal evidence to a specific

treatment (clinician expertise and client values) and external (best available research evidence).

Approaches that are well researched◦ With the population specifically◦ Used with other populations◦ What is good or useful research?

Theory driven◦ What is the theory underlying the approach?◦ Some approaches that are well researched are

not theory driven Maybe a combination of both

◦ Careful, thoughtful consideration of best evidence

la Systematic review of two or more high-quality randomized controlled clinical trials (RCTs) showing similar direction and magnitude of results

lb Individual high-quality RCT with results surrounded by a narrow confidence interval

2a Systematic review of two or more high-quality cohort studies showing similar direction and magnitude of results

2b Individual high-quality cohort study or low-quality RCT

2c Outcomes research; ecological studies

3a Systematic review of case-control studies showing similar direction and magnitude of results

3b Individual high-quality case-control study

4 Case series or poor quality cohort or case-control studies

5 Expert opinion without explicit critical appraisal, evidence from physiology, bench research, or first principles (i.e., axiomatic)

Thinking about level encourages all or none thinking◦ Should not discount lower levels of evidence, if

this is the best available at the time. ◦ Should look at lower levels as a call to action or

with some suspicion, but still useful if clinician expertise or client values dictate the use. More on that in a minute.

◦ Research should not get a bad rap either, we need to find the best available evidence.

Treatment Efficacy◦ Large group or single subject study ◦ Careful selection of participants (ideal)◦ Precise control of treatment

variables/environment◦ Use of a well trained clinician◦ High in internal validity, may lack external validity

Treatment effectiveness◦ Can be single case studies, large or small groups◦ Measure the effectiveness of therapy as it

actually occurs, under typical clinical conditions. ◦ Lacks control, but allows for naturalistic

measurement of the benefits of treatment as it actually occurs.

As an ethical clinician, prepared to work using E3BP you should have:◦ Healthy uncertainty whether a clinical action is

optimal for a client. Honest doubt.◦ Professional integrity-comprising honesty,

respectfulness, awareness of biases, and openness to the need to change one’s mind.

A clinician may state: I do what works, because I know it works

Certainly, clinical expertise can be very good evidence, even the highest level, if this expertise is based on thoughtful consideration of theory and evidence

Less is known or studied about client values in treatment, but we know that they need to be a part of the decision

Little research has explored this◦ Yaruss et all reported that clients reported many benefits of

therapy beyond speech changes◦ One study by Cream et al (2003) found that a group of clients

reported not wanting to use fluency techniques◦ May not like doing certain techniques◦ Maintaining changes in fluency is quite hard◦ Bring a lot of experience to the table, but also might be

misinformed or have had bad experiences◦ Venkatagiri (2009)

Fluency or freedom??

Rodney Gabel, Ph.D., CCC-SLP, BRS-FD

Beneficence◦ Approaches we choose should have maximum benefit

for our clients and their families. Nonmalificence

◦ Minimize harm. I would go farther and suggest “do no harm.”

Autonomy◦ Clients are individuals, not numbers or disorders. We

need to value their need for self-determination. ◦ We must respect their rights to make choices about

what happens to them. Justice

◦ We should strive for fairness in all we do. Be advocates for our clients and families. Never discriminate.

We should have doubt about what we are doing, and search for answers instead.

Avoid subjective bias. ◦ We need to be skeptical about expert opinion and

testimonials We can find resources that help us explore

the right answers.

Questions have four parts:◦ Patient or Problem◦ Intervention- treatments and diagnostic tools◦ Comparison or Contrast to the intervention◦ Outcome of the intervention

Patient Elderly patients with AphasiaIntervention

Constraint Induced Intensive therapy

Comparison

No therapy

Outcome Increase communication abilities

Patient Preschoolers who stutterIntervention

Lidcombe program

Comparison

No therapy

Outcome Reduce stuttering