Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
A Case-Based Approach to Teaching                   Evidence-Based Practice and Motor                   Speech DisordersRo...
a process and resources to help students figure things out             Teaching the EBP Processfor themselves. In case-bas...
cultural, or ethnic values and expectations. Help        the client weigh intervention alternatives among        ILLUSTRAT...
− Summary of the levels of evidence according to                       o The highest priorities for using AAC by in-      ...
o Clinical observation revealed that the client           − PICO          is highly motivated to use ACC and has good     ...
o Observation of an adult with MG using an                              based on clinical opinion and an assessment of    ...
the clinical decision-making process. The case-based ap-         individual, not a group or population of clients. Informi...
Davidson, L., Hale, L., & Mulligan, H. (2005). Exercise prescrip-            therapy, speech pathology, and occupational t...
Upcoming SlideShare
Loading in …5

Couture Speech Of Henderson, NV Shares A Case Based Approach to Teaching EBPotor speech disorders


Published on


Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Couture Speech Of Henderson, NV Shares A Case Based Approach to Teaching EBPotor speech disorders

  1. 1. A Case-Based Approach to Teaching Evidence-Based Practice and Motor Speech DisordersRonald L. BloomHofstra University, Hempstead, NYO ver the last decade, the principles of evi- dence-based practice (EBP) that emerged from medicine have become integrated intodisciplines in the behavioral sciences, health care, andeducation. Motivated in part by current standards from the Although EBP concepts may be infused into the cur- riculum in communication disorders, students may not have exposure to the intricate steps involved in implementing the process. According to Schlosser and Raghavendra (2004), the EBP process entails “the integration of best and currentAmerican Speech-Language-Hearing Association (ASHA, research evidence with clinical/educational expertise and2004a), concepts including the rationale for the use of EBP relevant stakeholder perspectives, in order to facilitate deci-and the value of locating quality external evidence have sions about assessment and intervention that are deemedbeen infused into both academic and clinical education in effective for a given stakeholder” (p. 3). This article de-speech-language pathology. In addition, practice guidelines scribes a case-based approach to teaching students to applyand clinical protocols are frequently interjected into content EBP procedures in the context of a graduate class in motorcourses on communication disorders to give students the speech disorders.most up-to-date information on diagnosis and treatment. Much of the content presented in the motor speech disorders class is taught through direct instruction using conventional means such as lecture, audiovisual presenta- ABSTRACT: Principles of evidence-based practice (EBP) tions, and readings. Students are grounded in relevant have been gradually infused into the undergraduate neurological concepts, information about perceptual and and graduate curriculum in speech-language pathology. acoustic characteristics and neural correlates of speech However, the multiple steps involved in the EBP process disorders, and theories about speech motor control and its require substantial background in research methods and clinical implications. There are, of course, certain limita- ample exposure to a variety of communication disorders tions to having students acquire material through logic and and clinical practice procedures. This article will describe deductive reasoning alone. For example, student motivation a case-based approach for teaching graduate students to use EBP procedures to treat motor speech disorders may be decreased because students cannot immediately see in adults. This teaching strategy was used successfully the relevance of the material as it relates to their clinical to facilitate students’ understanding of the inextricable careers. A substantial literature suggests that students may connection between research and clinical practice in be better motivated through inductive teaching methods communication disorders. Two case studies, developed (Coles, 1985; Norman & Schmidt, 1992). Research suggests by graduate students, illustrate how the students used that inductive teaching methods may encourage students to the EBP process to make well-informed decisions about adopt a deeper (Ramsden, 2003) and more scholarly ap- treatment. proach to learning (Felder & Brent, 2004) than by listening to lectures and studying for an exam. KEY WORDS: evidence-based practice, motor speech Case-based teaching is an inductive strategy wherein the disorders instructor provides a particular problem to solve as well asCONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS • Volume 37 Bloom: Teaching EBPNSSLHA • 123–130 • Fall 2010 © and Motor Speech Disorders 123 1092-5171/10/3702-0123
  2. 2. a process and resources to help students figure things out Teaching the EBP Processfor themselves. In case-based teaching, students explorehypothetical scenarios that mirror what they will encounter Before enrolling in the motor speech disorders class, stu-in professional practice (Ludenberg, Levin, & Harrington, dents completed a graduate-level class in research meth-1999). For students in communication disorders, this estab- ods. Thus, they came to class with experience in criticallylishes the close connection between accessing and evaluat- evaluating research, accessing research databases, and writ-ing current research, generating sound research hypotheses, ing research reports. As such, students had some exposureand providing clinical services. The EBP process provides to the principles and purposes of EBP, but they were nota framework for case-based learning as well as an opportu- required to explicitly apply the process clinically beforenity for students to build on their conceptual understanding enrolling in the class. Because clinical expertise is such anand develop the skills they need to reach informed clinical important component of the EBP process, all students indecisions. However, the process and multiple steps involved the class had a minimum of two semesters of supervisedin EBP present several challenges to students. practicum in at least two settings. Engagement in the EBP process requires considerable At the beginning of the semester, the EBP process wasbackground knowledge in research methods as well as am- defined and systematically broken down into five steps,ple exposure to a variety of communication disorders and largely based on Sackett, Rosenberg, Gray, Haynes, andclinical practice procedures. Students must be familiar with Richardson (1996). Students were provided with guidelinesresearch design principles to appraise the extant literature, describing how to progress through the EBP process (Sack-and they must have sufficient clinical experience in order ett et al., 1996) as well as resources to help clarify theto assert their expert opinion and involve clients as partners steps involved in the process (e.g., Dollaghan, 2004, 2007;in treatment. For these reasons, the approach described here Robey, 2004; Schlosser & O’Neil-Pirozzi, 2006). A list ofis envisioned as a capstone experience for graduate students readily accessible databases was provided. By the thirdat the later stages of the curriculum. week of class, the instructor met with each group to ensure Active participation in an assignment of this nature re- that they had formulated an answerable question and thatquires that students have an understanding of how to access they were able to locate and access appropriate databases.various databases as well as the principles of experimental The steps of the EBP process were modified from Sackettdesign. An understanding of objective measurement and a et al. and included the following parameters:grasp of concepts related to reliability, internal and external • STEP 1: Identify and formulate an answerable clinicalvalidity, and statistical significance is crucial to being able complete a critical appraisal of the evidence. Meaning- − Using the case study, identify the problem or popu-ful participation in the EBP process also necessitates that lation (P), the intervention (I), a comparison inter-students have had exposure to treating clients with com- vention or no intervention (C), and the outcome ofmunication disorders in a variety of settings. It is essential interest (O).that students have completed some supervised practicumand that they have experience in providing client-centered − Formulate a well-built clinical question (Schlossertreatment that shows an appreciation of individual differ- & O’Neil-Pirozzi, 2006).ences and cultural variations in communication style. • STEP 2: Locate the best available evidence. Limitations in students’ experiences are not the only − Search for evidence that includes practice guide-challenge to introducing the EBP process into the class- lines, systematic reviews, and individual studies us-room. Not only does participation in the EBP process ing a variety of databases (e.g., Cochrane Databaserequire prerequisite knowledge and skills, but it also entails of Systematic Reviews, PsychLit, ASHA PubMed,a willingness to alter conventional thinking about clini- etc.).cal practice. Because EBP has the potential to modify ourpreconceived notions of what we believe works in treat- − Summarize the findings and develop a bibliography.ment, it requires openness to alternative ways of problem • STEP 3: Critically appraise the evidence.solving. Providing a clinical rationale based on experience − Evaluate the evidence on the Evaluating Treatmentalone, even when justified with a literature citation, may Evidence form (Sackett et al., 2000) and code theno longer comply with the demand for time-limited and level of evidence.outcome-based services in medical and educational set-tings. EBP procedures suggest that we have an obligation − Create a summary statement that demonstrates howto provide efficacious treatment that takes into account the the findings may be organized to assist in makingcost and benefit of services rendered. That is, EBP chal- a clinical decision.lenges the traditional, rationale-based approach to treat- • STEP 4: Integrate the evidence with the client’sment that has guided clinical practice in the past. Positive unique biology, preferences, and values.classroom experiences may address some of the resistance − Present the evidence that guided the clinical deci-to embracing EBP. A case-based approach to EBP, placed at sion.a strategic point in the curriculum, allows the instructor tobuild on students’ current level of knowledge by extending − Present each client with the highest quality options.experiences in research into a practical approach to address − Determine a course of care with the client. Incorpo-clinical questions. rate any unique circumstances, including personal,124 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS • Volume 37 • 123–130 • Fall 2010
  3. 3. cultural, or ethnic values and expectations. Help the client weigh intervention alternatives among ILLUSTRATIVE CASE STUDIES best practice options. Two case studies completed by students will be presented − Specify the clinical recommendations. in this article to illustrate how the students advanced • STEP 5: Evaluate the EBP process. Self-evaluate the through each step of the EBP process. Each case presen- group’s performance in completing the process and tation will outline how the group combined current best identify goals for improving EBP skills. evidence with clinical expertise and the client’s personal values, expectations, and preferences to make well-informed − Was the clinical question well formulated? decisions about treatment. − Was the best external evidence located? − Was the external evidence appraised critically? Case Study 1 − Did the clinical decision integrate the best current evidence with clinical expertise and client values? One year ago, JS, a 61-year-old retired attorney, was diag- nosed with amyotrophic lateral sclerosis (ALS) with bulbar signs. ALS is a progressive disease of the nerve cells inThe EBP Assignment the brain and spinal cord that control voluntary muscleFor this particular project, students were placed in a group movement. JS’s speech intelligibility had started to declineand assigned a case history. Each case study was designed and his pulmonary function had declined over the year,to be a realistic, context-based depiction of a clinical sce- with particularly severe reduction in measures of air flow.nario in motor speech disorders. In addition, cases present- In addition, his oral diadochokinesis and measures of vo-ed a fairly open-ended clinical problem that required the cal function (including jitter, shimmer, and signal-to-noisegroup to elaborate on certain details (Herreid, 2005). Group ratio) were highly variable across test is ideal for case-based learning because it mimics the The team of graduate student collaborators, includingcollaborative structure of a research (Greenwald, 2006) or Jeanne Calvo, Jennifer Maultasch, Mariel Phillips, Kristenclinical team (Pena & Quinn, 2003). Evidence suggests that Vavoules, and Mathew Weiss, implemented the followinginteractions in a group assist students to define pertinent steps to determine the best treatment for JS.issues, move through the steps needed to solve problems, • STEP 1: Identify and formulate an answerable clinicaland communicate their ideas verbally and in writing (Gre- question.enwald, 2006). Each group was required to document all of the EBP − PICOprocess steps and determine the best course of care for the o Population: Adult male, age 61, with ALS, 1case it was assigned. Direct instruction continued through- year after onsetout the semester, but the instructor met with the groups o Intervention: Augmentative and alternative com-periodically to ensure that they were successfully mov- munication (AAC)ing through the steps of the EBP process. The required o Comparative intervention: Behavioral treatmentcomponents of the assignment included a written report and directed at improving respiration, phonation,30-min oral presentation of the following information: resonance, and articulation • An elaboration of the case history, including back- o Outcome of interest: To prolong functional com- ground information and relevant medical history munication as the disease progresses • An evaluation of the client that provides a plausible − Focused clinical question: Which treatment, AAC perceptual description of the client’s speech, as well or behavioral intervention, is most effective at as an assessment guided by the Frenchay Dysarthria prolonging functional communication in adults with Assessment—Second Edition (Enderby & Palmer, ALS? 2008) • A handout of no more than five pages with references • STEP 2: Locate the best available evidence. and supplementary resources − The following databases were searched: Academic • A treatment plan that demonstrates how the client Search Premiere, ASHA PubMed, ASHA Web site, might progress over time ERIC, PsychInfo, Medline, Science Direct, and Google Scholar. • Documentation and a demonstration of how the EBP process was used to guide the approach to treatment − A total of 32 articles were identified as having potential for contributing evidence to the clini- The latter portion of the assignment, documenting the cal question. Of the 32 articles, eight contributedfive steps of the EBP process, is the focus of this article. some evidence to answering the clinical question.Groups were graded on the clarity, relevance, and depth However, none of the studies contrasted the twoof their presentation as well as their documentation of the approaches within the same study or meta-analysissteps of the EBP process. The project, including the presen- (see bibliography).tation and written documentation, was due at the end of thesemester. • STEP 3: Critically appraise the evidence. Bloom: Teaching EBP and Motor Speech Disorders 125
  4. 4. − Summary of the levels of evidence according to o The highest priorities for using AAC by in- Sackett, Straus, Richardson, Rosenberg, & Haynes dividuals with ALS were getting their needs (2000): met, clarifying their needs, giving instructions, o Ball, Beukelman, & Pattee (2004): Level II: and staying connected with family and friends Quasi-experimental (Fried-Oken et al., 2006). o Beukelman, Fager, Ball, & Dietz (2007): Level o Individuals with ALS rely heavily on low-tech IA: Meta-analysis devices in the early stages of the disease, with an increased reliance on high-tech options dur- o Doyle & Philips (2001): Level IV: Observational ing the middle stages and a return to low-tech study without controls approaches during the late stages (Doyle & o Fried-Oken et al. (2006): Level II: Quasi- Philips, 2001). experimental o According to Richter et al. (2003), individuals o Kuhnlien et al. (2008): Level IA: Meta-analysis preferred listening to clients with ALS when an o Richter, Ball, Beukelman, Lasker, & Ullman AAC device was used rather than just listening (2003): Level II: Quasi-experimental to the natural speech of clients with ALS. o Watts & Vanryckeghem (2001): Level IV: − Present each client with the highest quality options: Observational study without controls o Introduce AAC; provide information on AAC o Yorkston (1996): Level IA: Meta-analysis systems in the context of client and family − Three meta-analyses were reviewed; there were no counseling. well-designed randomized control trials. The major- o Provide behavioral treatment that includes ity of the studies reviewed were quasi- strengthening and preserving respiration for experimental in that the research was well designed speech purposes, implementing voice therapy but not randomized. No direct comparison of AAC for improving intensity, and using compensa- and behavioral treatment in ALS was found. tory articulation strategies to maximize speech • STEP 4: Integrate the evidence with the client’s intelligibility. unique biology, preferences, and values. o Provide no treatment at this time. − Present the evidence that guided the clinical deci- − Determine a course of care: sion: o Communicate the different treatment options to o There were no randomized control trials, which the client and his family. are considered to be the strongest intervention o Discuss with the client and family the advan- design. Therefore, a clinical decision was made tages and disadvantages of behavioral speech by pooling data from available sources and therapy and AAC as approaches to intervention. integrating this information with client values o The current research suggests that behavioral and clinician expertise based on observation of intervention is not effective in clients with ALS the individual. due to the progressive nature of the disorder o Due to the progressive nature of the disorder, (Beukelman et al., 2007). behavioral treatments are ineffective. Isomet- o If no intervention is offered, it would sig- ric exercises and work on oral motility, voice nificantly compromise JS’s quality of life. He strengthening, and loudness practice can reduce would be unable to express basic needs, and vocal quality and speech intelligibility (Watts & limitations in his communication would affect Vanryckeghem, 2001). his social relationships. o In cases where the progression of the disease o Research suggests that the use of AAC may be is slow, compensatory strategies may be taught. the most effective means of prolonging commu- However, these remedies are only temporary nication abilities in clients with ALS. because of the progressive nature of the disease (Kuhnlien et al., 2008). o Given JS’s declining speech intelligibility as well as his intelligence, motivation, and level o Timing of the referral for AAC intervention of family involvement, speech therapy directed is the most important clinical decision. The at improving and maintaining communication speech-language pathologist (SLP) should rec- through the use of an AAC device is recom- ommend AAC to individuals with ALS when mended. their speaking rate reaches 100–125 words per minute on the Speech Intelligibility Test (Beu- − Specify the clinical recommendations: kelman et al., 2007). o Due to the progressive nature of ALS, an early o Findings indicate that 96% of people with ALS introduction to the use of AAC is recommended. accepted AAC without discontinuing use of the Not implementing AAC at the appropriate time device (Ball et al., 2004). will limit JS’s future communication abilities.126 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS • Volume 37 • 123–130 • Fall 2010
  5. 5. o Clinical observation revealed that the client − PICO is highly motivated to use ACC and has good o Population: Adult male, age 67, with moderate family support, which are important factors in generalized late-onset MG making the clinical decision. o Intervention: Respiratory exercises o A multidisciplinary team to maintain JS’s qual- o Comparative intervention: No intervention from ity of life should be assembled. an SLP • STEP 5: Evaluate the EBP process: o Outcome of interest: To strengthen respiration − The clinical question was well formed. for speech and, ultimately, improve his overall − There was a sense that there was limited access to quality of life as the disease progresses certain databases, which restricted the search for − Focused clinical question: Does behavioral interven- evidence. The group did not know when it had tion directed at increasing respiration help improve obtained sufficient information to fully answer the communication function in an adult with MG? clinical question. − Among group members, only one had exposure to • STEP 2: Locate the best available evidence. a client with ALS. Although most group members − The following databases were searched: EBSCO had course work and experience with individu- host, PubMed, Medline, Google Scholar, ERIC, als who used AAC devices, there was uncertainty ASHA Web site, Highbeam. about conducting an AAC evaluation and taking − A total of 44 articles were identified as having part in the collaborative decision-making process. potential for contributing evidence to the clini- − The limited amount of available evidence for the cal question. Of the 44 articles, seven contributed treatment options was presented to the family. Be- some evidence to answering the clinical question cause there were no studies that directly compared (see bibliography). AAC with behavioral therapy, the research was used cautiously to inform the treatment recom- • STEP 3: Critically appraise the evidence. mendation. The course of treatment was determined − Summary of the levels of evidence according to primarily by understanding the client’s values and Sackett et al. (2000): goals. The clinical decision was made based on an o Baker et al. (2003): Level IV: Observational integration of the best evidence, clinical expertise, study without controls and the perspectives of the client and family. o Davidson, Hale, & Mulligan (2005): Level IV: In addition to documenting and presenting the five steps Observational study without controlsof the process, the students provided supplementary infor- o Fregonezi, Resqueti, Guell, Pradas, & Casanmation about the nature of ALS and ALS with bulbar signs (2005): Level I: Well-designed randomizedin particular, as well as information on the progression control trialof the disease with emphasis on communication changes.Further, information about introducing an AAC device in o Koessler et al. (2001): Level IV: Observationalstages that correspond to the progression of the disease was study without controlsprovided. o Morris et al. (2006): Level IA: Meta-analysis o Rassler et al. (2007): Level IV: ObservationalCase Study 2 study without controlsWH, age 68, was diagnosed with myasthenia gravis (MG), o Skeie et al. (2006): Level IA: Meta-analysiswhich is a chronic autoimmune neuromuscular disease char- of well-designed control study plus literatureacterized by varying degrees of weakness of the voluntary review of additional lower level evidencemuscles. Muscles that control eye and eyelid movements, − The majority of the studies reviewed were observa-facial expression, chewing, talking, and swallowing are in- tional. In addition, there were two meta-analyses,volved. More recently, WH’s muscles that control breathing one that examined well-designed control studies,and neck and limb movements have become affected. WH and one that included a meta-analysis of random-reported that he takes medication to improve his neuro- ized control trials as well as a review of the litera-muscular transmission and increase his muscle strength. He ture on lower quality evidence.firmly rejects the use of an AAC device but is questioningif speech therapy would be of benefit to his communica- • STEP 4: Integrate the evidence with the client’stion. unique biology, preferences, and values. The team of graduate student collaborators, including − Present the evidence that guided the clinical deci-Lev Fridman, Elissa Karol, Kristen Peterson, and Jonathan sion:Wise, implemented the following steps to determine the o The evidence included many observational stud-best treatment for WH. ies, so claims of a relationship between treat- • STEP 1: Identify and formulate an answerable clinical ment and respiratory improvement may not be question. substantiated. Bloom: Teaching EBP and Motor Speech Disorders 127
  6. 6. o Observation of an adult with MG using an based on clinical opinion and an assessment of inspiratory muscle training program produced the individual’s needs. a substantial increase in her ability to generate o Delay of myasthenia crisis, a sudden and critical maximal inspiratory pressures. A phasic relation- worsening of respiratory function or profound ship between the diaphragm and the posterior weakening in the muscles, is a primary goal of cricoarytenoid suggests that the increased therapeutic intervention (Kothari, 2004). strength of the diaphragm would also enhance o Clinical expertise indicated that the flaccid the activity of the posterior cricoarytenoid dysarthria resulting from MG is best managed (Baker et al., 2003). medically through surgery or pharmacological o Exercise was a factor in reducing fatigue in a intervention. Behavioral speech treatment for participant with MG and restoring her partici- MG may be contraindicated (Duffy, 2005). pation in functional activities (Davidson et al., − Specify the clinical recommendations: 2005). o Discuss with the client and family the typical o Following a program of interval-based inspira- progression of the disease, including probable tory muscle retraining, improvements in respira- changes in eating and swallow function. tory strength, chest wall mobility, respiratory pattern, and respiratory endurance were observed o Counsel the client about techniques that can be in clients with MG (Fregonezi et al., 2005). used to avoid fatigue, such as limiting speaking to short durations. o With inspiratory muscle training, respiratory function can be improved for at least 2 years o Provide referral to an appropriate allied health (Koessler et al., 2001). professional for respiratory strength training. o Given the progressive nature of motor neuron o No speech therapy is indicated at this time. diseases, treatment should focus on altering the Recommend follow-up when needed. environment and educating key people to maxi- • STEP 5: Evaluate the EBP process. mize residual function (Morris et al., 2006). − The clinical question may have been strengthened o Respiratory muscle endurance therapy was ef- by having a comparison intervention. fective in improving lung function in some, but − Students expressed concern that they were missing not all, clients with MG (Rassler et al., 2007). important information from certain databases. There However, there is no indication that respira- was uncertainty about how much research was tory muscle endurance therapy had a positive enough to answer the question. outcome on speech breathing. − Limited clinical exposure to a wide range of neu- o Pharmacological approaches to treating MG romuscular diseases was seen as a limiting factor predominate in the literature. There is a lack of in the decision-making process. Students relied on research on lifestyle modifications and respira- Duffy (2005) to validate their expert opinion. tory therapies to treat MG (Skeie et al., 2006). − Students confessed their reluctance to acknowledge − Present each client with the highest quality options: that behavioral speech therapy was contraindicated. o Provide counseling regarding the typical course − Students reported that their clinical decision in- of the disorder and reintroduce the idea of using cluded the integration of research, client values, AAC. and expertise. There was a striking lack of usable evidence to directly address the question, so expert o Provide behavioral treatment focused on improv- opinion and consultation with the client held more ing the client’s respiratory strength and endur- weight in determining the course of care than ance. originally anticipated. o Provide counseling and support regarding the Case study 2 was supplemented by medical information use of compensatory strategies such as using on MG and a detailed explanation of the progression of the shorter phrases and using smaller breath groups. disease (Turner, 2007). An explanation of an inspiratory o Provide no treatment at this time. muscle training device was also provided. To support its clinical recommendation, the team clarified the distinction − Determine a course of care: between nonspeech breathing and speech breathing. o Communicate the treatment options to the client and family, noting the client’s adamant rejection of AAC. Summary o There is an absence of large-scale random- The EBP process described here creates a collaborative ized clinical trials. Observational studies fall learning environment in which students discover for them- short of providing a cause-and-effect relation- selves the need to integrate external evidence with expert ship between treatment and outcome. Therefore, opinion and client values. The assignment gives students an recommendations for speech therapy are largely opportunity to access, evaluate, and integrate research into128 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS • Volume 37 • 123–130 • Fall 2010
  7. 7. the clinical decision-making process. The case-based ap- individual, not a group or population of clients. Informingproach guides students to weigh various treatment options, clients about the expected course of treatment and the out-select the most efficacious intervention, or recommend no come is consistent with EBP practices because it acknowl-treatment at all. edges the client and his or her family as active participants The case-based approach to teaching EBP reveals for in their own care. The application of EPB principles to thestudents the reciprocal relationship between research and diagnosis and treatment of individual clients must be partclinical training. In Case Study 1, the students recognized of clinical education in communication disorders.the progressive nature of the disorder and acknowledged Although EBP is purportedly highly valued among SLPs,that implementing AAC early in the course of the disease it is unclear to what extent EBP is used in everyday clini-would maximize the client’s future communication abili- cal practice. In fact, students often perceive a mismatchties. The decision not to use behavioral speech therapy was between “best practices” taught in class and real-worldinformed by research, but not solely determined by it. The clinical practices. In a survey of certified SLPs, Zipoli andstudents reported that there were no studies that directly Kennedy (2005) reported a significant decline in exposurecompared ACC and behavior therapy. Although research to EBP as students moved from graduate programs to thecontributed to the decision-making process, it was not the clinical fellowship. University programs in speech-languageonly source for determining the course of care. Even high- pathology play a key role in teaching EBP. Students whoquality evidence must be integrated with clinical exper- view EBP as an extension of their clinical interests aretise and relevant client perspectives to determine the best more likely to use EBP in their work settings. An under-course of care for an individual client. In Case Study 2, the standing of the EBP process should be made transparentstudents reported that it was disconcerting not to recom- to students before they move from training programs tomend treatment. Although inspiratory muscle strengthening professional practice.may be achieved in some clients with MG, the team noted Implementing EBP is an ongoing, evolving processthat there was no evidence suggesting that respiration for that reflects a change in the way speech-language pathol-speech purposes could be improved. Nonspeech breathing, ogy services will be delivered. The foundation of clinicalthey determined, was better managed by another health care decision making in speech-language pathology is presentlyprovider. Observational studies were acknowledged, but undergoing a shift from a reliance on conventional wisdomthey were used judiciously in making decisions about treat- to practices based on the integration of clinical expertise,ment. An advantage of using EBP as a teaching tool is that best current research evidence, and individual client valuesstudents are encouraged to weigh clinical opinion against (ASHA, 2004b). EBP is a practical response to the de-the available evidence in order to determine the best course mand for changes in the way health care is administered.of care for their client. Students and practitioners must learn to use EBP to make The student perspectives on the process provide an informed clinical decisions and to advocate for healthopportunity to examine how EBP principles are being care policies that include rehabilitation services for motorimplemented. Students in this instance often commented speech disorders and other chronic conditions.on the lack of quality external evidence, which is a frankevaluation of the need to conduct clinical trials in speech-language pathology. Many students reported that they wereunsure when they had completed a sufficient review of the REFERENCESliterature to address the problem at hand. However, the American Speech-Language-Hearing Association. (2004a).students did recognize that the search for clinical evidence Evidence-based practice in communication disorders: An in-is an ongoing process. Ultimately, the answer to decid- troduction [Technical report]. Available from if a review is sufficient lies in their self-evaluation of org/members/deskref/default.the process. At the same time, more systematic research American Speech-Language-Hearing Association. (2004b). Reportis needed to test treatment approaches that are directed at of the Joint Committee on Evidence-Based Practice. Availableimproving the communication of adults living with chronic from speech disorders. Resources must be created to dis- 8A09-4113139CE5CE/0/JCCEBPReport04.pdf.seminate information that can be useful to clinicians. It is Baker, S. E., Sapienza, C. M., Martin, D., Davenport, P., Hoff-the instructor’s obligation to update the list of databases man-Ruddy, B., & Woodson, G. (2003). Inspiratory pressurethat students have access to and ensure that the library threshold training for upper airway limitation: A case of bilateralresources of the university are adequate to address the abductor vocal fold paralysis. Journal of Voice, 17, 384–394.problem. Ball, L. J., Beukelman, D. R., & Pattee, G. I. (2004). Accep- Frequently, the clinician must make a clinical decision tance of augmentative and alternative communication technologyon the basis of limited quality evidence. In the absence of by persons with amyotrophic lateral sclerosis. Augmentative andquality evidence, students need to be instructed in strate- Alternative Communication, 20, 113–122.gies that include the use of single-subject designs (Horner Beukelman, D. R., Fager, S., Ball, L., & Dietz, A. (2007). AACet al., 2005) and the concept of time-limited trial therapy for adults with acquired neurological conditions: A review. Aug-to measure the impact of treatment and objectively assess mentative and Alternative Communication, 23, 230–242.its costs and benefits for individuals receiving services. As Coles, C. R. (1985). Differences between conventional and prob-Schlosser and O’Neill-Pizzoli (2006) pointed out, decisions lem based curricular in their students’ approaches to studying.based on EBP have an effect on the services provided to an Medical Education, 19, 308–309. Bloom: Teaching EBP and Motor Speech Disorders 129
  8. 8. Davidson, L., Hale, L., & Mulligan, H. (2005). Exercise prescrip- therapy, speech pathology, and occupational therapy for people tion in the physiotherapeutic management of myasthenia gravis: with motor neuron disease: A systematic review. Neurorehabili- A case report. New Zealand Journal of Physiotherapy, 33, tation and Neural Repair, 20, 424–434. 13–18. Norman, G., & Schmidt, H. (1992). The psychological basis ofDollaghan, C. (2004). Evidence-based practice in communication problem based learning: A review of the evidence. Academic disorders: What do we know, and when do we know it? Journal Medicine, 67, 557–565. of Communication Disorders, 37, 391–400. Pena, E. D., & Quinn, R. (2003). Developing effective collabora-Dollaghan, C. (2007). The handbook for evidence-based practice tion teams in speech-language pathology. Communication Disor- in communication disorders. Baltimore, MD: Brookes. ders Quarterly, 24(2), 53–63.Doyle, M., & Philips, B. (2001). Trends in augmentative and Ramsden, P. (2003). Learning to teach in higher education (2nd alternative communication use by individuals with amyotrophic ed.). London, England: Taylor & Francis. lateral sclerosis. Augmentative and Alternative Communication, Rassler, B., Hallebach, G., Kalischewski, P., Baumann, I., 17, 167–178. Schauer, J., & Spengler, C. (2007). The effect of respiratoryDuffy, J. R. (2005). Motor speech disorders: Substrates, dif- muscle endurance training in patients with myasthenia gravis. ferential diagnosis, and management (2nd ed.). St. Louis, MO: Neuromuscular Disorders, 17, 385–391. Elsevier Mosby. Richter, M., Ball, L. J., Beukelman, D. R., Lasker, J., & Ull-Enderby, P., & Palmer, R. (2008). Frenchay Dysarthria Assess- man, C. (2003). Attitudes toward communication modes and ment—Second Edition. Austin, TX: Pro-Ed. message formulation techniques used for storytelling by peopleFelder, R. M., & Brent, R. (2004). The intellectual develop- with amyotrophic lateral sclerosis. Augmentative and Alternative ment of science and engineering students. Part 1. Models and Communication, 19(3), 170–186. challenges. Journal of Engineering Education, 93, 269–277. Robey, R. (2004, April 13). Levels of evidence. The ASHA Leader. Retrieved from Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richard- public/Papers/IntDev-I.pdf. son, W. (1996). Evidence-based medicine: What it is and what itFregonezi, G. A. F., Resqueti, V. R., Guell, R., Pradas, J., & isn’t: It’s about integrating individual clinical expertise and the Casan, P. (2005). Effects of eight week, interval-based inspira- best external evidence. British Medical Journal, 312, 71–72. tory muscle training and breathing retraining in patients with Sackett, D., Straus, S., Richardson, W., Rosenberg, W., & generalized myasthenia gravis. The American College of Chest Haynes, R. (2000). Evidence-based medicine: How to practice Physicians, 128, 1524–1530. and teach EBM. Edinburgh, Scotland: Churchill Livingstone.Fried-Oken, M., Fox, L., Rau, M., Tullman, J., Baker, G., Schlosser, R. W., & O’ Neil-Pirozzi, T. M. (2006). Problem Hindal, M., ... Lou, J. (2006). Purposes of AAC device use for formulation in evidence based practice and systematic reviews. persons with ALS as reported by caregivers. Augmentative and Contemporary Issues in Communication Science and Disorders, Alternative Communication, 22, 209–221. 33, 5–10.Greenwald, M. L. (2006). Teaching research methods in commu- Schlosser, R. W., & Raghavendra, P. (2004). Evidence-based nication disorders: A problem-based approach. Communication practice in augmentative and alternative communication. Aug- Disorders Quarterly, 27(3), 173–179. mentative and Alternative Communication, 20, 1–21.Herreid, C. F. (2005). Using case studies to teach science. Ameri- Skeie, G. O., Apostolski, S., Evoli, A., Gilhus, N. E., Hart, I. can Institute for Biological Sciences. Retrieved from http://ac- K., & Harms, L. (2006). Guidelines for the treatment of auto- immune neuromuscular transmission disorders. European JournalHorner, R., Carr, E., Halle, J., McGee, G., Odom, S., & Wol- of Neurology, 13, 691–699. ery, M. (2005). The use of single subject research to identify Turner, C. (2007). A review of myasthenia gravis: Pathogenesis, evidence-based practice in special education. Exceptional Chil- clinical features and treatment. Current Anaesthesia & Critical dren, 71, 165–179. Care, 18, 15–23.Koessler, W., Wanke, T., Winkler, G., Nadar, A., Toifl, K., Watts, C. R., & Vanryckeghem, M. (2001). Laryngeal dysfunction Kurtz, H., & Zwick, H. (2001). 2 years’ experience with inspi- in amyotrophic lateral sclerosis: A review and case report. BMC, ratory muscle training in patients with neuromuscular disorders. Ear, Nose and Throat Disorders, 1, 1. The American College of Chest Physicians, 3, 765–769. Yorkston, K. M. (1996). Treatment efficacy: Dysarthria. Journal ofKothari, M. J. (2004). Myasthenia gravis. Journal of the American Speech and Hearing Research, 39, S46–S57. Osteopathic Association, 104(9), 377–384. Zipoli, R. P., & Kennedy, M. (2005). Evidence-based practiceKuhnlien, P., Gdynia, H., Sperfeld, A. D., Lindner-Pfleghar, B., among speech-language pathologists: Attitudes, utilization and Ludolph, A. C., Prosiegel, M., & Riecker, A. (2008). Diagnosis barriers. American Journal of Speech-Language Pathology, 14, and treatment of bulbar symptoms in amyotrophic lateral sclero- 208–220. sis. Neurology, 4, 366–374.Ludenberg, M., Levin, B., & Harrington, H. (1999). Who learns Contact author: Ronald L. Bloom, Hofstra University, Depart- from what cases and how? The research base for teaching and ment of Speech-Language-Hearing Sciences, Davison Hall, Hemp- learning with cases. Mahwah, NJ: Erlbaum. stead, NY 11549. E-mail:, M. E., Perry, A., Bilney, B., Curran, A., Dodd, K., Wittwer, J. E., & Dalton, G. W. (2006). Outcomes of physical130 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS • Volume 37 • 123–130 • Fall 2010