1. 2009 Adult Language Group NSW Speech Pathology Evidence Based Practice NETWORK
Janine Mullay, Kate Schuj and Anika Roseby (Group Co-Leaders)
Lyndsey Nickels - Academic Member
Clare McCluskey (nee Owens) – 2009 Extravaganza Presenter

2. TIPS FOR ANSWERING A CLINICAL QUESTION?
Ask a question that can be answered
Ask a question that is relevant to clinical decision making
Ask a question that is specific
Use the 4 key components in the question:
1. The patient/problem
2. Intervention
3. Comparison intervention/test
4. Outcome
Search broadly at first before specifying the question
Consider ‘how and in what circumstances a treatment improves a certain impairment’
You may need to be less specific or more specific once you start searching.
Ask a question that will help your practice
Rather than, “therapy for aphasia” which will produce a lot of results, think about what type of aphasia you are interested in – groups? Expressive? Jargon? Too many results can be hard to negotiate.
The components improve the likelihood of your question being clinically relevant to you and your group.
Being specific will help you to refine your searches, but being too specific too early may yield you no results in your search! It is a fine balance. Your hospital or area heath service librarian is a wonderful asset here.
We found this wording helpful in being a ‘catch-all’ for effectiveness. It took us a while to get to it though!

3. CLINICAL QUESTION 2009
What are the effective therapy techniques currently being used to improve auditory comprehension deficits in people with aphasia?
Intervention targeting severe auditory comprehension deficits is challenging and the prognosis for communicative recovery is considered poor. The 2 predominant aims were to (i) confirm that evidence based techniques are being used (ii) investigate further therapy techniques that can be used in targeting auditory comprehension deficits.

4. 2009 CAPS (CRITICALLY APPRAISED PAPERS)
12 possible articles were found
Only 3 answered our clinical question and were included in the CAT
Remediation of auditory comprehension deficits needed to be addressed by the study to be included and all study subjects had auditory comprehension deficits as a result of stroke

5. Behrmann & Lieberthal (1989)
All treated items showed increased semantic comprehension both intra- and post- therapy compared with pre-therapy
Multimodal approach was used (auditory semantic cues, spoken, written and picture form of the treated words)
Therapy tasks included:
- teaching meaning/semantics of treated categories and items within categories
- written and verbal word to picture matching
- auditory semantic feature to picture matching
- matching spoken and written words to each other
- locating items/target words in dictionary
Single case study, , total of 15 one hr sessions over a 6 week period. Category specific therapy. No generalisation of therapy to untreated categories, but generalisation did occur on untreated items within treated categories.

6. Grayson, Hilton & Franklin (1997)
Specific therapy targeting auditory, semantic and sentence processing resulted in significant improvements in these areas on specific tests.
Therapy cues included repetition, gesture, semantic and orthographic cues.
Specific therapy tasks included spoken word- picture matching, categorizing pictures into separate groups, matching written word associates and auditory sentence-picture matching.
Retrospective single case study cross-over design (i.e. allowing for evaluation), 3 specific therapies varying in intensity delivered over a 4 week period.

7. Maneta, Marshall & Lindsay (2001)
Impairment-based therapy for word sound deafness may not be effective treatment for chronic aphasia
Therapy targeting the use of effective compensatory strategies with primary communication partners can lead to significant functional gains and decreased communication breakdowns in conversation.
Impairment based therapy involved use of lip reading and cued speech, discrimination of initial sounds in minimal pairs task, phoneme-grapheme matching, matching spoken to written words and spoken word to picture matching.
Training compensatory strategies involved providing a written info. Booklet to the carer regarding the subjects strengths and weaknesses. These strategies were modelled and practiced in 12 x 30min sessions (twice a week for 6 weeks).
Strategies included writing key words/phrases, simplifying speech, checking comprehension in conversation.
Didn’t generalize to other communication partners.

8. Applying the results to clinical practice
Aim to increase your confidence in critically evaluating a paper;
Trust that evidence based practice will improve your skills as a clinician;
Test yourself and your boundaries;
Try it out and share your success!
Being comfortable with critiquing a paper takes some practice. It is only after thinking carefully about what we read that we were able to modify our techniques. We used peer-reviewing to improve our accuracy in analysing papers, at least two members of the group read each paper and reviewed each other’s CAP
The aim of EBP is to constantly examine our methods. Using EBP gives us the tools to use the best evidence for any given patient.
It is important to try to integrate new techniques into our everyday therapy, if we continue to use the same methods because they are comfortable we risk not treating the patient’s specific disorder. That trying many options is often the way to get results from individual patients. We made application to clinical practice a big part of our meetings and learned a lot from each other.
Some of our members say that trying a technique immediately after learning (or reading about it) it helps to encourage confidence. And we made sure to share it with our EBP group colleagues and our departments too.

9. Applying the 2009 results to clinical practice
Small number of studies (three)
And small ‘n’
BUT Speech Pathology = single case studies!
No ‘right answer’ or single solution
1. We discussed the small number of studies which answered our question
2. And the fact that only three patients’ results were reported (n=3 is a small number).
3. SP evidence is often made up of single case studies. We ensured that the design was strong and the level of evidence was adequate ( NH&MRC level IV or above ). We know that a RCT is considered to be the “gold standard” for clinical research and that single case designs are of the lowest form of evidence as per NH&MRC. However a study conducted by Tate et al (2008) pertaining to the quality of single case designs reported that RCT’s for research into aphasia are minute.
Furthermore, Guyatt et al (1990) as cited in Tate et al reported that there are a number of instances where treatment decisions in clinical practice cannot be guided by the results of a RCT. These instances include: candidate situations, rare conditions, and cases where patient characteristics differ from those defined in RCT’s. In these types of instances Guyatt et al advocate the use of single case designs.
Tate et al reports that single case designs represent “intensive and prospective study of the individual” and reports that the singular advantage of the single case design is it’s flexibility and capacity to individually tailor an intervention to the specific characteristics of the individual. As a result single case designs have a “ready application to clinical practice and are useful for documenting individualized outcomes and providing empirical evidence in support of therapeutic interventions.
4. We learned that like much of the data on people with aphasia, there is no one solution for everybody and that the addition of more skills as a clinician is always useful. It also goes to show that writing up case studies on particular clients can assist in the development of the speech pathology profession.

10. 2009 CAT (Critically appraised Topic)
Clinical bottom line:
Auditory comprehension deficits may benefit from specific speech therapy treatment techniques.
Direct therapy using a multimodal approach may be beneficial in improving comprehension of treated items.
Family training regarding the use of compensatory strategies can lead to significant functional gains, including decreased number of communication breakdowns in conversation.

11. REFERENCES
Behrmann, M. & Lieberthal, T. (1989). Category-specific treatment of a lexical-semantic deficit: A single case study of global aphasia. British Journal of Disorders of Communication, 24,
Grayson E, Hilton R & Franklin S. (1997). Early intervention in a case of jargon aphasia: efficacy of language comprehension therapy. European Journal of Disorders of Communication, vol. 32, pp
Maneta A, Marshall J, Lindsay J. (2001). Direct and indirect therapy for word sound deafness. International Journal of Language & Communication Disorders, 36(1):
Tate, R.L; McDonald, S; Perdices, M; Togher, L; Schultz, R; & Savage, S. (2008). Rating the methodological quality of single- subject designs and n-of-1 trials: Introducing the Single-Case Experimental Design (SCED) Scale. Neuropsychological Rehabilitation An International Journal, Vol 18 (4), pp