2. a process and resources to help students figure things out Teaching the EBP Process
for themselves. In case-based teaching, students explore
hypothetical 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 critically
lishes 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 exposure
and providing clinical services. The EBP process provides to the principles and purposes of EBP, but they were not
a framework for case-based learning as well as an opportu- required to explicitly apply the process clinically before
nity for students to build on their conceptual understanding enrolling in the class. Because clinical expertise is such an
and develop the skills they need to reach informed clinical important component of the EBP process, all students in
decisions. However, the process and multiple steps involved the class had a minimum of two semesters of supervised
in 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 was
background 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, and
clinical practice procedures. Students must be familiar with Richardson (1996). Students were provided with guidelines
research 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 the
to 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 of
is envisioned as a capstone experience for graduate students readily accessible databases was provided. By the third
at 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 that
quires 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 Sackett
design. 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 clinical
validity, and statistical significance is crucial to being able question.
to 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 of
munication disorders in a variety of settings. It is essential
interest (O).
that students have completed some supervised practicum
and that they have experience in providing client-centered − Formulate a well-built clinical question (Schlosser
treatment 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 Database
require 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 our
preconceived 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 Treatment
alone, even when justified with a literature citation, may
Evidence form (Sackett et al., 2000) and code the
no 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 how
to provide efficacious treatment that takes into account the the findings may be organized to assist in making
cost 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’s
ment 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 to
build 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. 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 in
The EBP Assignment the brain and spinal cord that control voluntary muscle
For this particular project, students were placed in a group movement. JS’s speech intelligibility had started to decline
and 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-noise
group to elaborate on certain details (Herreid, 2005). Group ratio) were highly variable across test sessions.
work is ideal for case-based learning because it mimics the The team of graduate student collaborators, including
collaborative structure of a research (Greenwald, 2006) or Jeanne Calvo, Jennifer Maultasch, Mariel Phillips, Kristen
clinical team (Pena & Quinn, 2003). Evidence suggests that Vavoules, and Mathew Weiss, implemented the following
interactions 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 clinical
and communicate their ideas verbally and in writing (Gre- question.
enwald, 2006).
Each group was required to document all of the EBP − PICO
process steps and determine the best course of care for the o Population: Adult male, age 61, with ALS, 1
case it was assigned. Direct instruction continued through- year after onset
out 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 treatment
components 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 contributed
five 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 two
of their presentation as well as their documentation of the
approaches within the same study or meta-analysis
steps of the EBP process. The project, including the presen-
(see bibliography).
tation and written documentation, was due at the end of the
semester. • STEP 3: Critically appraise the evidence.
Bloom: Teaching EBP and Motor Speech Disorders 125
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. 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 controls
of the process, the students provided supplementary infor-
o Fregonezi, Resqueti, Guell, Pradas, & Casan
mation about the nature of ALS and ALS with bulbar signs
(2005): Level I: Well-designed randomized
in particular, as well as information on the progression
control trial
of the disease with emphasis on communication changes.
Further, information about introducing an AAC device in o Koessler et al. (2001): Level IV: Observational
stages that correspond to the progression of the disease was study without controls
provided. o Morris et al. (2006): Level IA: Meta-analysis
o Rassler et al. (2007): Level IV: Observational
Case Study 2 study without controls
WH, age 68, was diagnosed with myasthenia gravis (MG), o Skeie et al. (2006): Level IA: Meta-analysis
which is a chronic autoimmune neuromuscular disease char- of well-designed control study plus literature
acterized by varying degrees of weakness of the voluntary review of additional lower level evidence
muscles. 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 questioning
if speech therapy would be of benefit to his communica- • STEP 4: Integrate the evidence with the client’s
tion. 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. 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 into
128 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS • Volume 37 • 123–130 • Fall 2010
7. the clinical decision-making process. The case-based ap- individual, not a group or population of clients. Informing
proach 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 the
students the reciprocal relationship between research and diagnosis and treatment of individual clients must be part
clinical 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 mismatch
ties. The decision not to use behavioral speech therapy was between “best practices” taught in class and real-world
informed by research, but not solely determined by it. The clinical practices. In a survey of certified SLPs, Zipoli and
students reported that there were no studies that directly Kennedy (2005) reported a significant decline in exposure
compared ACC and behavior therapy. Although research to EBP as students moved from graduate programs to the
contributed to the decision-making process, it was not the clinical fellowship. University programs in speech-language
only source for determining the course of care. Even high- pathology play a key role in teaching EBP. Students who
quality evidence must be integrated with clinical exper- view EBP as an extension of their clinical interests are
tise 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 transparent
students reported that it was disconcerting not to recom- to students before they move from training programs to
mend treatment. Although inspiratory muscle strengthening professional practice.
may be achieved in some clients with MG, the team noted Implementing EBP is an ongoing, evolving process
that 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 clinical
they determined, was better managed by another health care decision making in speech-language pathology is presently
provider. Observational studies were acknowledged, but undergoing a shift from a reliance on conventional wisdom
they 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 values
students 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 health
opportunity to examine how EBP principles are being care policies that include rehabilitation services for motor
implemented. Students in this instance often commented speech disorders and other chronic conditions.
on the lack of quality external evidence, which is a frank
evaluation of the need to conduct clinical trials in speech-
language pathology. Many students reported that they were
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