Reader Response Log #2
Renee White
1/20/2008
American Speech-Language-Hearing Association (2004). Evidence-based practice in
communication disorders: An introduction [Technical Report]. Available from
TAP
This article addresses evidence-based practice within the field of speech and language pathology and audiology. In the article, the authors define the concept of evidence-based practice as “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. The authors go into detail about the principles of evidence-based practice and provide suggestions to professionals within the field of communication disorders for better incorporating evidence-based practice within their clinical work with patients in both diagnosis and treatment.
The audience that this article speaks to consists of speech-language pathologists, audiologists, researchers of communication disorders, and other medical professions/researchers that deal with communication disorders.
The purpose of this reading is to describe the relevance of evidence-based practice in the field of communication disorders, to provide an overview of the principles and procedures associated with evidence-based practice, to raise awareness of the importance of evidence-based practice, and to make recommendations for increasing the amount of credible evidence to support diagnostic measures and treatments within the field of communication disorders.
Claim(s)
The authors, members of ASHA’s Research and Scientific Affairs Committee, claim that not all research is completely credible. The evidence-based practice orientation developed the authoring committee, claims that there are different levels of evidence. The article included a table (see Table 1) describes the levels of evidence commonly used within the field of communication disorders. The table presented 6 levels; the highest level being a well-designed meta-analysis of >1 randomized controlled trial and the lowest being a clinical experience of respected members of the field. These levels were adapted from the Scottish Intercollegiate Guideline Network and are not used in all professional fields. The levels of evidence within different professional fields vary however, this article claims that five common themes appear to contribute to the evaluation and ratings of the quality of evidence. The five themes being independent confirmation and converging evidence, experimental control, avoidance of subjectivity and bias, effect sizes and confidence intervals, and relevance and feasibility.
Evidence
The claim that not all research is completely credible was supported by Sackett, Haynes, Guyatt, & Tuggwell (1991) who noted a number of cases in which the clinical expertise of respected members of medical field have turned out to be wrong or harmful when subjected to scientific investigation. Examples of this was found in William Osler’s recommendation that opium was a good treatment for diabetes and in the “best practice” recommendation of oxygenating premature infants to prevent retrolental fibroplasias (Sackett et al). According to Meehl (1997), as cited in this technical report, oxygenating premature infants ended up causing retrolental fibroplasia, instead of curing or preventing it. The above two pieces of information show evidence that clinical expertise may not always be accurate and is not rated a high level of evidence when alone.
Connections
Text-to-self: The information presented in this article was familiar to me because of the material that was covered in the CD 601 Research course that I took last semester. The course discussed the levels of evidence and the factors that make information more reliable and valid. The factors discussed in the course were the type of design, experimental designs were rated higher than quasi-experimental designs; biases, studies conducted by the owner/inventor of a specific treatment were more bias and rated lower than studies conducted by someone other than the owner/inventor of a treatment; randomization, studies that were completely randomized were considered more reliable than those that consisted of self-selected groups.
Text-to-text: Reading this article made me think of the text Clinical Research In Communication Disorders by M.N. Hegde. Within this text, the concepts of validity and reliability were discussed along with the factors that contribute to the rating of the level of evidence. The contributing factors that were discussed in the Hedge text and Gruber et al article were very similar. The factors being bias, controlling for extraneous factors, the type of research design, the number of participants, a single study verses a meta-analysis, etc.
Text-to-world: This articles related to the broader world of clinical practice because much of the treatment approaches used clinically are justified only by clinical expertise. This article gives examples of when clinical expertise was not enough and was later found to be wrong. The article describes the different levels of evidence and suggests that practicing speech-language pathologist supplement their clinical expertise with higher levels of evidence such as a meta-analysis of well-controlled studies.
Reader Response Log #1
Renee White
1/18/2008
Gruber, F., Lowery, S., Seung, H., & Deal, R. (2003). Approaches to speech-language intervention and
the true believer. Journal of Medical Speech-Language Pathology, 11(2), 95-104.
TAP
This article addresses the fact that speech-language pathologists select treatment approaches based on their clinical observations that “it works.” Although, clinical expertise and/or experience is one component of evidence-based practice, this component alone is not sufficient. Gruber et al (2003) discuss five extraneous factors that can influence the treatment outcomes; the placebo effect, the Hawthorne effect, the natural history effect, the experimenter effect, and regression to the mean. The article presents ways that each extraneous factor can influence the treatment outcomes and provides ways that therapists/researchers can control for each extraneous factor in order to gain more reliable evidence of the efficacy of the treatment approaches.
The audience that this article speaks to consists of speech-language pathologists, researchers of communication disorders, and other medical professions/researchers that deal with communication disorders.
The purpose of this reading is to increase the awareness that clinical expertise alone is not a strong piece of evidence for supporting the use of a treatment approach. The article informs the reader of the extraneous factors that influence treatment outcomes and provides ways to control for those factors in order to collect more reliable evidence to add to the component of clinical expertise.
Claim(s)
Gruber et al claim that clinical judgment or the statement “because it works” do not provide a sound basis for evaluating the efficacy of treatment approaches. They claim that there are five extraneous factors that can influence the outcome of a treatment approach. These five extraneous factors being the placebo effect, the Hawthorne effect, the natural history effect, the experimenter effect, and regression to the mean. They provide ways to control for the extraneous factors and claim that speech-language pathologists should use research/studies that controlled for the extraneous factors along with clinical judgments to justify the use of a treatment approach.
Evidence
The claim that extraneous factors do exist and that they influence treatment outcomes was supported by the research about extraneous factors conducted by the medicine, psychology, and alternative medicine fields (Moerman & Jonas, 2000; Weil, 1997). According to the preceding sources, these professional fields use the beneficial results of extraneous factors as treatment. The claim that the placebo effect is an extraneous factor was supported by research conducted by Peck & Coleman, 1991; Turner, Deyo, Loeser, von Korff, & Fordyce, 1994) that showed the participants’ perceptions of being given a form of assistance and the belief of the treatment will be beneficial enhanced the outcomes. According to van Wassenaer et al (1997), drug trials using the placebo effect have even been done on infants born at less than 30 weeks gestation. An experiment by Rosenthal and Jakobson (1966) revealed the experimenter effect in a study conducted on kids in primary classrooms. The kids were given IQ tests and a randomly selected group of children were falsely identified as having an unusually high potential for intellectual growth to their teachers. After eight months the kids were given an IQ test again and those identified as having an unusually high potential for intellectual growth had higher IQ scores than the controls. Regression of the mean has been found to influence the treatment outcomes in the field of speech language pathology. A study conducted by Tomblin, Zhang, and Buckwalter (1997) found that even in a well-controlled sample of children that were screened for language delay regression of the mean accounted for all the improvement in the language scores. The above summarized evidence supports the claims that Gruber et al made concerning the influence of extraneous factors on the treatment outcomes within the field of communication disorders.
Connections
Text-to-self: The information presented in this article was familiar to me because of the material that was covered in the CD 601 Research course that I took last semester. The factors that can jeopardize the validity and reliability of a study/experiment, such as the extraneous factors in this article were discussed in the course. Ways to control for the extraneous factors were discussed and a research proposal was assigned and controls for the extraneous factors were required in the proposal, if necessary.
Text-to-text: Reading this article made me think of the text Clinical Research In Communication Disorders by M.N. Hegde. Within this text, the concepts of validity and reliability were discussed along with the factors that possibly negatively affect the validity and/or reliability of a study. The contributing factors that were discussed in the Hedge text and Gruber et al article were very similar. These extraneous factors being the natural history effect, the experimenter effect, statistical regression, bias, maturation, etc.
Text-to-world: This articles related to the broader world of clinical practice because much of the treatment approaches used clinically are justified only by clinical expertise the statement that “it just works.” This article explains and gives support that more reliable and valid research needs to be conducted in order to determine the efficacy of many treatment approaches within the field of speech-language pathology.
