A N O N - S Y S T E M A T I C R E V I E W O F E V I D E N C E - B A S E D P R A C T I C E W I T H I N S P E E C H P A T H O L O G Y I N A U S T R A L I A S h a ry n n e M c L e o d C harles S tu rt U niversity, A ustralia f A bstract In this n o n -s y s te m a tic review , e v id e n c e -b a s e d p ra c tic e (EBP) in A u stralia n speech p a th o lo g y research a n d p ra c tic e is ex­ a m in e d . M a n y A u stralia n resea rc h e rs a r e c o n tr ib u tin g to th e th e o re tic a le v id e n c e th ro u g h s y s te m a tic r e v ie w s , ra n d o m is e d c o n tro lle d trials, a n d o th e r clinical research. A d d itio n a lly , A ustralian researchers are in te g ra tin g in te rn a tio n a l th e o re tic a l e v id e n c e via speechBITE ™ and o th e r in itia tives. A ustralian s peech p a th o lo g is ts 'c lin ic a l e x p e rtis e is s u p p o rte d via S p eech P a t h o lo g y A u s tr a lia a n d a n e x a m p le o fth e im p le m e n ta tio n o f EBP in clinical co n te x ts is th e N SW EBP N e tw o rk . W ith in Aus­ tralia, research a tte n tio n also has b e e n d ire c te d to w a rd s th e c lie n t's c h o ic e a n d th e c lie n t's v o ic e .T h is p a p e ra c k n o w le d g e s lim ita tio n s o f im p le m e n tin g EBP in A ustralia: s u g g e s tin g t h a t inclu sion o f th e client's vo ice c o u ld b e fo rm a lis e d a n d th a t a d d itio n a l research n e e d s to b e u n d e rta k e n to a d d re s s practical d iffe re n c e s in service d e liv e ry m o d e ls b e tw e e n A ustralian an d in te rn a tio n a l contexts. K e y w o rd s : E v id e n c e -b a s e d p ractice, A ustralia, profession al p ractice, s p e e c h -la n g u a g e p a th o lo g y , ICF. Evidence-based practice ( E B P ) is increasingly encour­aged within the health and medical professions as a method to underpin clinical decision making. Based on the definition o f Sackett, Rosenberg, Gray, Hayes, and Richardson (1 9 9 6 ), E B P is considered to have three com ­ ponents: theoretical evidence, clinical expertise and client’s choice. In this paper, these three components will be con­ sidered by drawing on examples o f research and practice un­ dertaken within the field o f speech pathology in Australia W h ile the author has aimed to represent a broad overview o f E B P in Australia, it is acknowledged that this paper does not present a systematic review. To contextualise this paper, Australia is a country o f over 2 0 million people and is one o f the most multicultural coun­ tries in the world (Hugo, 2 0 02). I t is primarily populated along the coasts with the largest population centres being Sydney, Brisbane and Melbourne on the east coast, whereas inland Australia is sparsely populated. Distance and remote­ ness bring challenges to the provision o f health care within Australia. Healthcare in Australia is freely available for all through government funding and there is also opportunity for privately funded healthcare. Speech pathology is pro­ vided through the health, education and disability sectors by the Australian government as well as through private prac­ tices; however, this non-centralised approach coupled with geographical barriers can mean that some people do not have access to the amount o f speech pathology services they require (e.g., M cL eo d & M cK innon, 2 0 0 7 ; O ’Callaghan, M cAllister & W ilson, 2005a). The traditions o f speech pa­ thology practice in Australia were originally influenced by Britain; however, over the years the Australian speech pa­ thology profession has been acknowledged for drawing on, synthesising and enhancing perspectives from throughout the world. Currently, there are eight universities that pro­ vide professional preparation programs for speech patholo­ gists and Speech Pathology Australia (www.speechpatholo- gyaustralia.org.au) is the peak professional body for speech pathologists. Theoretical evidence The first component o f E B P mentioned by Sackett et al. (1996) is theoretical evidence. According to Australia’s N a­ tional H ealth and M edical Research Council (N H M R C ) (2 000, p. 7 -8 ) the highest level o f evidence for “assessing clin­ ical and public health interventions” is “a systematic review o f all relevant randomised controlled trials”. The next high­ est is “evidence obtained from at least one properly designed randomised controlled trial”. Key Australian speech pathol­ ogy researchers have been at the cutting edge in undertak­ ing systematic research regarding interventions for people with communication disorders. For example, an Australian, Angela M organ has co-authored a Cochrane Systematic Review on the topic o f intervention for developmental apraxia o f speech (Morgan & Vogel, 2 0 06). The Australian Stuttering Research Centre (A S R C ) has conducted ran­ domised controlled trials to demonstrate the effectiveness o f the Lidcom be Program for preschool children who stutter (e.g., Jones et al., 2 0 0 5 ; Jones et a l , in press). Randomised controlled trials also have been conducted in Australia re­ garding interventions for chronic cough (Vertigan, Theod­ oras, Gibson, & W inkw orth, 2 0 0 6 ), the training o f com ­ munication partners o f people with traumatic brain injury (Togher, M cD onald, Code, & Grant, 20 0 4 ) and the train­ ing o f volunteers to assist people who have aphasia (W or- rall & Y iu, 2 0 0 0 ). Additionally, there is much research be­ ing undertaken within Australia that would be categorised ______________________________________ / Author Contact: Sharynne McLeod, PhD School o f Teacher Education, Charles Sturt University Panorama Ave, Bathurst, NSW, 2795, Australia Tel: +61-2-63384463 Fax: +61-2-63384417 E-mail: smcleod@csu.edu.au 16 | DIE SU ID -AFR IKA AN SETYDSK R IF VIR K O M M U N IK A S IE -A FW Y K IN G S , VO L. 5 5, 2 0 0 8 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) mailto:smcleod@csu.edu.au EBP IN A U S T R A L IA by N H M R C as providing “lower” levels o f evidence, yet is important for understanding the effectiveness and efficien­ cy o f intervention for people with communication disorders (Code, 2 0 00). Australian researchers have also been involved in synthe­ sizing available international evidence for speech pathology practice. Notably, a group o f Australian speech pathology ac­ ademics primarily from LaTrobe University have compiled and analysed evidence in their book E viden ce basedpractice in speech pathology (Reilly, Douglas & O ates, 2 0 0 4 ). This book critiques theoretical evidence for working with clinical pop­ ulations including people who have aphasia, acquired brain injury, stuttering, voice disorders, dysphagia, developmen­ tal language disorders, motor speech disorders, articulation and phonological disorders and those who use augmentative and alternative communication. Recently, Speech Patholo­ gy Australia, in association with The University o f Sydney has launched sp eechB IT E ™ (www.speechbite.com) “[t]o enable speech pathology clinicians and researchers to effi­ ciently access the best available evidence to inform speech pathology practice and research”. The free online database catalogues systematic reviews, randomised controlled tri­ als (R C T s), non-randomised controlled trials (n on -R C T s), case series and single case experimental designs (S C E D s) that are relevant to speech pathology practice. To enable clinicians to more easily interpret the scientific quality o f the research, R C T s, n o n -R C T s and S C E D studies are giv­ en a methodological rating and papers are listed according to their methodological quality. sp eech B IT E ™ is the most recently launched o f four databases which have been devel­ oped in Australia to facilitate the use o f E B P in clinical de­ cision making. The others include P E D ro for physiotherapy (www.pedro.fhs.usyd.edu.au), O T Seeker for occupational therapy (www.otseeker.com) and P sy cB IT E ™ for people working in the field o f acquired brain impairment (www. psycbite.com). 1 O ne o f the difficulties that Australians face with employ­ ing theoretical evidence generated in some international speech pathology studies, is that the recommended dosage o f intervention is not possible within the Australian health, education and disability sectors; frequently due to limited funding for services'. For example, many international stud­ ies recommend provision o f intervention twice a week to children; a service cielivery model that is rare within Aus­ tralia. W ith in the United Kingdom, Glogowska, Roulstone, Enderby, and Peters (2000) demonstrated in a pragmatic randomised controlled trial that i f children do not receive a high enough dosage o f intervention, then speech pathol­ ogy outcomes may be negligible. Furthermore, speech pa­ thologists are not employed by the government education system o f the largest state within Australia (New South Wales [N S W ]), so evidence-based interventions that have been designed for school settings are rarely able to be im ­ plemented. In addition to the importance o f considering the theo­ retical evidence, there are two other components to E B P as espoused by Sackett et al. (1 996, p. 71): “Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise.” Clinical expertise Speech pathology graduates from Australian universi­ ties are conversant with evidence-based practice guidelines. Each o f these university courses are accredited by Speech Pathology Australia and each graduate has met Com peten­ cy-Based Occupational Standards (C B O S ) (Speech Pathol­ ogy Australia, 2 0 0 1 ) demonstrating their clinical expertise. For example, in order to plan clinical intervention, entry lev­ el speech pathologists must demonstrate that they can “... give a rationale for decisions made with reference to: the client’s communication/swallowing history, the critical ap­ praisal o f evidence in current literature and research, clinical reasoning.” (Speech Pathology Australia, 2 0 0 1 , p. 9). Speech Pathology Australia supports the ongoing devel­ opment o f clinical expertise through evidence-based prac­ tice in many ways. I t publishes both an academic journal (In tern ation al Jo u r n a l o f Speech-Language Pathology, previ­ ously called Advances in Speech-Language Pathology) and a clinical journal (ACQ uiring Know ledge in Speech, Language a n d H earin g) that has a regular column titled “W h a t’s the evidence fo r...?” The association organises an annual sci­ entific conference that is attended by hundreds o f speech pathologists (including both national and international del­ egates). Additionally, it organises regular professional de­ velopment courses in each state that are presented by key researchers and clinicians. Speech Pathology Australia also provides a professional self regulation (P S R ) program to support and recognise continuing professional development o f Australian speech pathologists. Those who are involved in the P S R program are able to use the postnominals, C P S P (certified practicing speech pathologist). Around Australia speech pathologists are encouraged to apply evidence-based practice to their management o f peo­ ple with communication disorders. The N S W Speech Pa­ thology E B P Network (2008) is possibly the most formal­ ized method where this takes place. This E B P network was established in 2 0 0 2 so that speech pathologists could col- laboratively examine evidence to enhance their practice and is currently organised around the following clinical groups: augmentative and alternative communication, tracheostomy and critical care, paediatric language, paediatric phonology, paediatric feeding, adult swallowing, adult speech, adult lan­ guage, cleft palate. Each clinical group has their own terms o f reference and presents critically appraised papers and topics (CAPs and CATs) on the website and at their annual conference. Additionally, a number o f Australian researchers are in­ volved in translation o f research to clinical practice to sup­ port the development o f clinical expertise. Onslow, Jones, O ’Brian, and M enzies (in press) have recently written a tu­ torial paper to facilitate consum ers’understanding and inter­ pretation o f clinical trials o f stuttering treatments. A special issue o f Advances in Speech-Language Pathology (M cLeod, 20 0 6 ) provided readers with ten different perspectives from international experts on intervention approaches for Jarrod, a seven-year-old with unintelligible speech. The special issue TH E S O U T H A F R IC A N J O U R N A L OF C O M M U N IC A T IO N D ISO RD ER S, VO L . 55 2 0 0 8 | 17 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://www.speechbite.com http://www.pedro.fhs.usyd.edu.au http://www.otseeker.com S H A R Y N N E M C L E O D was accompanied by online video files to enable clinicians to develop their clinical expertise by reflecting on their clinical decision making for Jarrod. Shelton (1993, p. 175) indicated that “Clinicians need to make skillful use o f a tremendous store o f in form ation ...” Australian researchers have conducted research into speech pathologists’ professional practice. For example, M cLeod and Baker (2004) examined Australian speech pathologists’ clinical practice for children with speech impairment and W atts Pappas, M cL eod , M cAllister and M cK innon (2008) studied Australian speech pathologists’ practices for work­ ing with families. Client’s choice M any Australian researchers have a commitment to ex­ ploration o f the client’s choice and the client perspective. For example, Australian speech pathology researchers have talked with people who have aphasia (Cruice, Worrall 8c Hickson, 2 0 06), adolescents who stutter (Herane, Packman, Onslow 8c Quine, in press), stakeholders involved with peo­ ple who had a traumatic brain injury (Larkins, Worrall 8c Hickson, 2 0 0 4 ), parents o f children who have undergone newborn infant hearing screening (Mazlan, Hickson, 8c Driscoll, 20 0 6 ) and siblings o f children with speech impair­ ment (Barr, M cL eod 8c Daniel, 2008). Australian research has also considered clients’ opinions on the barriers o f ac­ cessing speech pathology services when they are in rural and remote locations (O ’Callaghan et a l , 2005b). Kovarsky (2008, p. 4 7) indicated that “The current version o f E B P needs to be reformulated to include subjective voices from the life-worlds o f clients as a form o f evidence.” Although not considered on the N H M R C levels o f evidence, explo­ ration and consideration o f the client’s voice is important within the Australian research context. Summary M any Australian speech pathologists have incorporated E B P within their clinical decision-making, strongly sup­ ported by Speech Pathology Australia. Along with many others throughout the world, Australian researchers have embraced and contributed to understanding the three dis­ creet and interconnected aspects o f E B P : theoretical evi­ dence, clinical expertise and client’s choice. In this paper it is suggested that formalised E B P categories could expand to further acknowledge client’s voices. Ray Kent, in his role as Vice President for Research and Technology o f the Am er­ ican Speech-Language-Hearing Association (A SH A ) de­ scribed the application o f E B P to the speech pathology and audiology professions in the U S A as follows “Evidence- based practice (E B P ) is a challenging but attainable goal for audiology and speech-language pathology. O ur profes­ sions have made rapid progress in developing the founda­ tions for EBP. To be sure, a great deal o f work remains to be done, but we have learned from the experiences o f other professions and have built our own systems to support E B P ” (Kent, 2 0 0 6 , p. 268). His words can be echoed in the Aus­ tralian context. References Code, C. (2000). The problem with RCTs. RCSLT Bulletin, 14- 15. March. Cruice, M . N , Worrall, L. E. 8c Hickson, L. M. H. (2006). Per­ spectives on quality of life by people with aphasia and their family: Suggestions for successful living. Topics in Stroke Reha­ bilitation, 1 3 ,14-24. Glogowska, M , Roulstone, S , Enderby, R, 8c Peters, T. J. (2000). Randomised controlled trial of community based speech and language therapy in preschool children. British Medical Journal, 3 2 1 ,1-5.14 October. Hearne, A , Packman, A , Quine, S , 8c Onslow, M. (2008). Stut­ tering and its treatment in adolescence: The perceptions of peo­ ple who stutter.Journal ofFluency Disorders. 3 3 ,2, 81-98. Hugo, G. (2002). Year book Australia: Centenary article—A centu- ry o f population change in Australia. Retrieved December 12, 2003 from http://www.abs.gov.aU/Ausstats/abs@.nsf/Lookup/ 0B82C2F2654C3694CA2569DE002139D9. Jones, M , Hearne, A , Onslow, M , Packman, A , Ormond, T., Williams, S , Schwarz, I , 8c O ’Brian, S. (2008). Extended fol­ low up of a randomised controlled trial of the Lidcombe Pro­ gram of Early Stuttering Intervention. International Journal o f Language and Communication Disorders. DOI: 10.1080/136828 20801895599. Jones, M , Onslow, M , Packman, A , Williams, S , Ormond, T., Schwarz, I , et al. (2005). Randomised controlled trial of the Lidcombe Program for early stuttering intervention. British Medical Journal, 331, 7518,659-663. Kent, R. D. (2006). Evidence-based practice in communication disorders: Progress not perfection. Language, Speech, and Hear­ ing Services in Schools, 3 7 ,4,268-270. Kovarsky, D. (2008). Representing voices from the life-world in evidence-based practice. International Journal o f Language and Communication Disorders, 43(1 supp 1), 47- 57. Larkins, B. M , Worrall, L. E. 8c Hickson, L. M. H. (2004). Stakeholder opinion of functional communication activities following traumatic brain injury. Brain Injury, 1 8 ,691-706. Mazlan, R , Hickson, L. M. H. 8c Driscoll, C. (2006). Measuring parent satisfaction with a neonatal hearing screening program. Journal o f the American Academy o f Audiology, 1 7, 4,253-264. McLeod, S. (2006). Editorial: Perspectives on a child with unintelligible speech. Advances in Speech-Language Pathology, 8,! 3,153-155. McLeod, S , 8c Baker, E. (2004). Current clinical practice for children with speech impairment. In B. E. Murdoch, J. Goozee, B. M. Whelan 8c K. Docking (Eds.), Proceedings o f the 26th World Congress o f the International Association o f Logopedics and Phoniatrics. Brisbane: University of Queensland. Morgan, A , 8c Vogel, A. (2006). Intervention for developmen­ tal apraxia of speech. Cochrane Database o f Systematic Reviews Issue 4. Art. No.: C D 006278, DOI: 10.1002/14651858. CD14006278. National Health and Medical Research Council (NHMRC) (2000). How to use the evidence: Assessment and application o f sci­ entific evidence. Canberra: Commonwealth of Australia. NSW Speech Pathology EBP Network (2008). NSWspeech pathol­ ogy evidence based practice. Retrieved June 16,2008 from http:// www.ciap.health.nsw.gov.au/specialties/ebp_sp_path/index. html. O’Callaghan, A. M , McAllister, L , 8c Wilson, L. (2005a). Barriers to accessing rural paediatric speech pathology services: Health care consumers’ perspectives. Australian Journal o f Rural Health, 1 3 ,3 ,162-171. 18 | DIE SU ID -AFR IKA AN SE TY DSK R IF VIR K O M M U N IK A S IE -A FW Y K IN G S , VOL. 5 5 ,2 0 0 8 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://www.abs.gov.aU/Ausstats/abs@.nsf/Lookup/ http://www.ciap.health.nsw.gov.au/specialties/ebp_sp_path/index EB P IN A U S T R A L IA O ’Callaghan, A. M., McAllister, L., 8c Wilson, L. (2005b). C o n s u m e r s ’ proposed solutions to barriers to access of rural and remote speech pathology services .Advances in Speech-Language Pathology, 7,2,58-64. Onslow, M., Jones, M ., O ’Brian, S., 8c Menzies, R. (in press). De­ fining, identifying, and evaluating clinical trials of stuttering treatments: A tutorial .American Journal ofSpeech-Language Pa­ thology. Reilly, S., Douglas, J., 8c Oates, J. (2004). Evidence based practice in speech pathology. Whurr Publishers: London. Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M ., Hayes, R. B., 8c Richardson, W. S. (1996). Evidence-based medicine: What it is and what is isn’t. British Medical Journal, 3 1 2 ,71-72. Speech Pathology Australia (2001). Competency-based occupational standards (CBOS) fo r entry level. Melbourne: The Speech Pa­ thology Association of Australia. speechBITE™ (2008). speechBITE™ Speech pathology database fo r best interventions and treatment efficacy. Retrieved June 16,2008 from http://www.speechbite.com. Togher, L„ McDonald, S., Code, C., 8c Grant, S. (2004). Training communication partners of people with traumatic brain injury. A randomised controlled trial, Aphasiology, 1 8 ,4 ,313-335. Vertigan, A. E.,Theodores, D. G., Gibson, P. G., Winkworth, A. L. (2006). Efficacy of speech pathology management for chronic cough: A randomised placebo controlled trial of treatment ef­ ficacy. Thorax, 6 1 ,12,1065-1069. Watts Pappas, N., McLeod, S., McAllister, L ., 8c McKinnon, D. H. (2008). Parental involvement in speech intervention: A national survey. Clinical Linguistics and Phonetics, 2 2 ,4 ,335-344. Worra]l L., 8c Yiu E. (2000). Effectiveness of functional communication therapy by volunteers for people with aphasia following stroke. Aphasiology, 1 4 ,9, 911-924. TH E S O U T H A FR IC A N J O U R N A L OF C O M M U N IC A T IO N DISORD ER S, V O L 5 5 2 0 0 8 19 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://www.speechbite.com