References. Apel, K., & Self, T. (2003). Evidence-based practice: The marriage of research and clinical service. The ASHA Leader, 8, 16, 6-7.

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1 References Apel, K., & Self, T. (2003). Evidence-based practice: The marriage of research and clinical service. The ASHA Leader, 8, 16, 6-7. Dollaghan, C. (2004, April 13). Evidence-based practice: Myths and realities. The ASHA Leader, pp. 4-5, 12. Gillam, S.L. & Gillam, R.B. (2006). Making evidence-based decisions about child language intervention in schools. Language, Speech, and Hearing Services in Schools, 37, Johnson, C. (2006). Getting started in evidence-based practice for childhood speechlanguage disorders. American Journal of speech-language Pathology, 15, Justice, M. & Fey, M.E. (2004, Sept. 21). Evidence-based practice in schools. The ASHA Leader, pp. 4-5,

2 Reference: Reference Analysis Worksheet 1 Purpose Statement: Participants: a. Number of Participants: Total #: Total # / group: *b. Participant selection: (age, gender, disorder-type, native language, etc.): c. Quality of subject description: (see descriptors on reverse side) because: *d. Randomization of participants *e. Control group: *f. Eligibility criteria/testing Appropriate? Method: a. Procedures: b. Time Period: c. Outcome Measures: *Quality of Outcome Measures: because (reliability/validity of tests used to determine effects): *Blind evaluators or treatment: Results: a. *Statistically Significant findings/*strong effect sizes: b. Other findings: 1 Based on American Academy of Cerebral Palsy and Developmental Medicine, 2002; ASHA, 2002; Ashford, 2002; Law, 2000

3 Overall Comments: Control of bias: Credibility of source: Appraisal points (add one point for each * item with a positive finding) /8 a. Level of Evidence: (see descriptors on reverse side) Levels of Evidence (ASHA, 2006): 1 Large randomized controlled trials / meta-analysis 2 Non-randomized study with control group(s); multiple baseline studies / single-subject design 3 Multiple cases studies 4 Single case study 5 Expert committee report, consensus conference, opinions of respected authorities. Rating Scale for Quality Judgments: Inadequate Adequate Excellent Article Abstract

4 Clinical Evidence Building Protocol (C-EBP) Form Clinical Question: Research: summarize findings from Reference Analysis Worksheet(s). Client-Family Factors (in order of importance): (1) list any important cultural or belief system considerations; (2) level of interest and involvement concerns for client/family; (3) financial restraints for client/family; (4) amount of time/effort required of family/caregivers; (5) client/family treatment preferences (not based on outcome study results). Clinician-Agency Factors (in order of importance): (2) clinician education, background and experience; (3) agency/facility policies, fiscal restraints; (4) clinician s own data addressing communication problem of interest; (5) clinician s philosophical/theoretical orientation, peer recommendations/suggestions. Decision-Making Summary Levels of Importance Factors Agree High Low Research Yes / No Client-Family Factors Yes / No Clinician-Agency Factors Yes / No From: Gillam, S.L. & Gillam, R.B. (2006). Making evidence-based decisions about child language intervention in schools. Language, Speech, and Hearing Services in Schools, 37(4), Decision: Based upon the multiple worksheet components, synthesize the information into your decision rationale. Decision: Implement Not Implement Rationale: Synthesize findings from table to support your decision.

5 EXAMPLES OF EBP DECISION-MAKING PROCESS

6 Reference Analysis Worksheet 2 Reference: Roy, N., Gray, S, D., Simon, M. Dove, H., Corbin-Lewis, K., Stemple, J. C. (2001). An evaluation of the effects of two treatment approaches for teachers with voice disorders: A randomized clinical trial. Journal of Speech, Language, Hearing Research, 44, Purpose Statement: To evaluate the effectiveness of two treatment methods for voice disorders in teachers: vocal hygiene (H) and vocal function exercises (VFE). Participants: a. Number of Participants: Total #: 58 Total # / group: 20 (H); 19 (VFE); 19 (Control) *b. Participant selection: (age, gender, disorder-type, native language, etc.): Adult teachers in Utah with self-reported voice problems at the time of the study or frequently in the past; all English speakers; unknown breakdown by gender or disorder type; groups were similar in participant number of years teaching and hours of teaching/day c. Quality of subject description: 2 (see descriptors on reverse side) because: number of missing data points including 45% of participant ages (the result of teachers returning incomplete questionnaires) reported by the authors; good description of the 11 clinicians providing the treatment *d. Randomization of participants _Yes, with statistical non-significance between groups *e. Control group: _Yes *f. Eligibility criteria/testing inclusion was based on a (qualitative) self-report of current or recent voice problems and not on quantification of the vocal disturbance_through testing Appropriate?_yes, when looking at psychosocial effect of voice problems as measured by the VHI Method: a. Procedures: A training session was held with 11 SLP s to explain the study, standardize administration of the VFE and VH program with written instructions provided. Voice treatment was provided in 4 1-hour (maximum duration) sessions (spaced 2 weeks apart) over the 6 week study period. The VFE group was provided with an audiotape to use with home practice. The VHI was administered at the initial and final sessions. The two treatment groups also completed a post-treatment questionnaire. Two contacts were made with the no treatment control group, at the initiation and end of the 6 week study period at which time they completed the VHI. b. Time Period: 6 weeks c. Outcome Measures: Vocal Handicap Index (Jacobson, 1997); 4 item posttreatment perceived benefit and compliance questionnaire; clinician confidence questionnaire 2 Based on American Academy of Cerebral Palsy and Developmental Medicine, 2002; ASHA, 2002; Ashford, 2002; Law, 2000

7 *Quality of Outcome Measures: 5 because (reliability/validity of tests used to determine effects): VHI is a validated instrument with strong internal consistency, reliability, and test-retest stability *Blind evaluators or treatment: _yes, blind evaluators Results: a. *Statistically Significant findings/*strong effect sizes: yes, statistically significant reduction in VHI scores for the VFE group only using repeated measures ANOVA and independent t-tests of VHI post-test means between the two treatment groups; the VFE group also reported perceived overall voice improvement and greater ease and clarity of voice (to a statistically significant level) while the other two groups did not; no statistically significant difference in reported compliance for the VFE or Vocal Hygiene group; no statistically significant finding in clinician confidence in delivering the two different treatments. Effect size was not reported. b. Other findings: Even given that clinicians reported more comfort administering a VH treatment program over the VFE program, the VFE treatment group reported significantly greater improvement. Overall Comments: Control of bias: 5 Credibility of source: 5 (peer-reviewed publication Appraisal points (add one point for each * item with a positive finding) 6/8 a. Level of Evidence: 1 (see descriptors below) Levels of Evidence (ASHA, 2006): 6 Large randomized controlled trials / meta-analysis 7 Non-randomized study with control group(s); multiple baseline studies / single-subject design 8 Multiple cases studies 9 Single case study 10 Expert committee report, consensus conference, opinions of respected authorities. Rating Scale for Quality Judgments: Inadequate Adequate Excellent

8 Article Abstract This prospective randomized clinical trial examined the effect of two different voice treatments in a group of teachers with self-reported voice problems. Participants were randomized into one of three groups no treatment control; Vocal Function Exercises (VFE) treatment; or Vocal Hygiene (VH) treatment group. The two treatments are theoretically different with the VFE treatment stressing exercise to strengthen and condition vocal fold performance while the VH method stresses reduction in phonotraumatic behaviors and use, a vocal diet approach. Groups were statistically compared at study initiation and found to be comparable across subject characteristics, problem severity and longevity, years teaching, and hours teaching/day. Following a 6 week treatment program consisting of 3 hour-long (maximum) sessions, the VFE group showed statistically significant improvement in vocal function as measured by the validated VHI instrument. Level of compliance differences between groups was negligible.

9 Clinical Evidence Building Protocol (C-EBP) Form Clinical Question: _Are Vocal Function Exercises (VFE) an appropriate treatment for a 55 year old female teacher who has been diagnosed with moderate muscle tension dysphonia (MTD) Research: summarize findings from Reference Analysis Worksheet(s). The Roy, et al. study demonstrated treatment effectiveness of VFE in a moderate-sized group of teachers based on self-report using the validated Vocal Handicap Index instrument. The study was a prospective randomized trial (Level 1 evidence). Client-Family Factors (in order of importance): (1) list any important cultural or belief system considerations; (2) level of interest and involvement concerns for client/family; (3) financial restraints for client/family; (4) amount of time/effort required of family/caregivers; (5) client/family treatment preferences (not based on outcome study results). Clinician-Agency Factors (in order of importance): (2) clinician education, background and experience; (3) agency/facility policies, fiscal restraints; (4) clinician s own data addressing communication problem of interest; (5) clinician s philosophical/theoretical orientation, peer recommendations/suggestions. Decision-Making Summary Levels of Importance Factors Agree High Low Research Yes / No Client-Family Factors Yes / No Clinician-Agency Factors Yes / No From: Gillam, S.L. & Gillam, R.B. (2006). Making evidence-based decisions about child language intervention in schools. Language, Speech, and Hearing Services in Schools, 37(4), Decision: Based upon the multiple worksheet components, synthesize the information and your decision rationale. Decision: Implement Not Implement Rationale: Synthesize findings from table to support your decision. The published research supports this treatment and there are no client-family, clinicianagency factors contraindicating the use of VFE with this patient.

10 Reference Analysis Worksheet 3 Reference: Huinck, W.J., Langevin, M., Kully, D., Graamans, K., Peters, H.F., Hulstijn, W. (2006). The relationship between pre-treatment clinical profile and treatment outcome in an integrated stuttering program. Journal of Fluency Disorders, 31(1), Purpose Statement: To evaluate the differences in treatment outcomes of subgroups of adults who stutter for two dimensions: stuttering severity and severity of negative emotions/cognitions related to stuttering. Participants: a. Number of Participants: Total #: 25 Dutch adults Total # / group: 4 groups of 6 with mild stuttering (MS) and mild emotional (ME) severity, 7 with severe stuttering (SS) and ME severity, 6 with MS and severe emotional (SE) severity, 6 with SS and SE severity. b. Participant selection: (age, gender, disorder-type, native language, etc.): 17 men, 8 women; age range years who had stuttered since before the age of 6. *c. Quality of subject description: 4 (see descriptors on reverse side) because: no mention of native language (assumed to be Dutch). Otherwise accurate and complete description of subjects noted. *e. Randomization of participants No *f. Control group: _No *g. Eligibility criteria/testing: Speech Behaviors: Stuttering Severity Instrument (SSI), naturalness judgments, Nijmegen Speech Motor Test. Inclusion in study required, at a minimum, a mild severity rating on SSI. Emotions and Cognitions Related to Stuttering: Perceptions of Stuttering Inventory (PSI), Lanyon s Stuttering Severity Scale (SSS), Inventory of Interpersonal Situations (ISS). Inclusion in study required scoring in the range of people who stutter on questionnaires. Appropriate? Yes, with regard to research question/relationship being studied. Method: a. Procedures: The study was set up as a factorial design with stuttering severity and severity of negative emotions and cognitions as between-subject variables and session (pre, post, F1, and F2) as the within subject variable. The Comprehensive Stuttering Program was administered in an intensive format (3 weeks) in The Netherlands by trained SLPs. Data was recorded daily by SLPs to determine the percentage of time spent on each area (stuttering vs. emotional and cognitive reactions to stuttering). Participants were tested pre-treatment, post-treatment, at 1-year follow-up and at 2-year follow-up to determine outcomes. b. Time Period: 3 weeks c. Outcome Measures: Speech fluency measurements: (1) Percentage of stuttered syllables for three-minutes in an interview, reading monologue, and telephone call. (2) 3 Based on American Academy of Cerebral Palsy and Developmental Medicine, 2002; ASHA, 2002; Ashford, 2002; Law, 2000

11 The distorted speech scale of the Speech Situation Checklist (Brutten). (3) Diadochokinesis task. Measures of introspective clinical characteristics: The emotional reaction scale of the Speech Situation Checklist. (2) Speech satisfaction rating scale. (3) The S24 attitude scale. *Quality of Outcome Measures: 5 because (reliability/validity of tests used to determine effects): obtained multivariate results and univariate results, as well as Pearson correlations. *Blind evaluators or treatment: No Results: *a. Statistically significant findings/*strong effect sizes: Yes. Significantly larger treatment effects were found in the MS group on the Emotional Reaction (ER) scores, suggesting an absent relation between stuttering severity and the severity of negative emotions and cognitions. The SS group had gained significantly more fluency (in terms of absolute gain) than the MS group; however, also had the highest level of regression. At the two follow-ups, both groups showed regression but severity still remained below pre-treatment levels. At post-treatment and both follow-up assessments, negligible differences on measures of emotions between the mild and severe emotional group were seen, largely due to a statistically significant decrease in the SE negative emotions and cognitions. Based on treatment gains, specific subgroups can be identified, each requiring different treatment approaches. b. Other findings: The authors suggested that individuals with MS profiles may benefit the most from treatment that focuses on decreasing their negative emotions/cognitions and helps them put their stuttering into perspective. Treatment of speakers with a severe profile may first need to focus on reducing the stuttering as a way of beginning to reduce their negative emotions and cognitions. Program data showed that 73.3% of the CSP treatment time was devoted primarily to targeting speech motor control, while 26.7% was devoted primarily to the reduction of the negative emotions and cognitions associated with stuttering. Overall Comments: Control of bias: 4 two of the investigators were authors of CSP. Credibility of source: 5 - credible (peer-reviewed journal) Appraisal points (add one point for each * item with a positive finding) 5/8 Level of Evidence: 2 (see descriptors below) Levels of Evidence (ASHA, 2006): 11 Large randomized controlled trials / meta-analysis 12 Non-randomized study with control group(s); multiple baseline studies / single-subject design 13 Multiple cases studies 14 Single case study 15 Expert committee report, consensus conference, opinions of respected authorities.

12 Rating Scale for Quality Judgments: Inadequate Adequate Excellent Article Abstract: Huinck et al. explored treatment outcomes for 25 adults who stutter with regard to two measures: stuttering severity and severity of negative emotions and cognitions associated with stuttering. Treatment was conducted in an intensive format (3 weeks) using the Comprehensive Stuttering Program (CSP). Outcome measures for stuttering severity and negative emotions/cognitions associated with stuttering were taken before treatment, after treatment, and at 1- and 2-year follow-up. Results revealed that (1) there was no relationship between stuttering severity and the severity of negative emotions/cognitions, (2) the severe stuttering group obtained the largest treatment gains with regard to fluency; however, also had the highest regression, (3) differences on measures of emotions between the mild and severe emotional groups had disappeared, due to the severe group s large decrease in negative emotions and cognitions. The authors suggested that distinct subgroups can be identified, and that different treatment interventions would be required.

13 Clinical Evidence Building Protocol (C-EBP) Form Clinical Question: Would using an integrated treatment approach with a 16 year old male presenting with mild stuttering and mild negative attitudes/cognitions related to stuttering, provide effective treatment? How much treatment time should be spent on each area to be effective in reducing both stuttering severity and negative emotions/cognitions related to stuttering? Research: summarize findings from Reference Analysis Worksheet(s). Huinck et al. (2006) found significantly larger treatment effects in the mild stuttering group on the emotional reactions scores, suggesting an absent relationship between stuttering severity and the severity of negative emotions/cognitions. Stuttering severity for both groups remained below pre-treatment levels (up to 2-years post treatment) with the severe group gaining significantly more fluency than the mild group; however, also demonstrating the highest level of regression. Treatment time devoted to speech skills was 73.3%, whereas treatment time devoted to the reduction of negative emotions/cognitions associated with stuttering was 26.7% in the study. Client-Family Factors (in order of importance): (1) list any important cultural or belief system considerations; (2) level of interest and involvement concerns for client/family; (3) financial restraints for client/family; (4) amount of time/effort required of family/caregivers; (5) client/family treatment preferences (not based on outcome study results). Clinician-Agency Factors (in order of importance): (2) clinician education, background and experience; (3) agency/facility policies, fiscal restraints; (4) clinician s own data addressing communication problem of interest; (5) clinician s philosophical/theoretical orientation, peer recommendations/suggestions. Decision-Making Summary: Levels of Importance Factors Agree High Low Published Research Yes / No Client-Family Factors Yes / No Clinician-Agency Factors Yes / No From: Gillam, S.L. & Gillam, R.B. (2006). Making evidence-based decisions about child language intervention in schools. Language, Speech, and Hearing Services in Schools, 37(4), Decision: Implement Not Implement

14 Rationale: Synthesize findings from table to support your decision. The published research supports this treatment, as well as reveals the percentage of time that was spent on each area to be effective. There are no client-family, clinician-agency factors to indicate otherwise.