EPISODE 67

[INTRODUCTION]

[0:00:04] MBH: Thanks for joining us at Keys for SLPs, opening new doors for speech-language pathologists to better serve clients throughout the lifespan, a weekly audio course and podcast from SpeechTherapyPD.com. I'm your host, Mary Beth Hines, a curious SLP who embraces lifelong learning. Keys for SLPs brings you experts in the field of speech-language pathology, as well as collaborative professionals, patients, and caregivers to discuss therapy strategies, research, challenges, triumphs, and career opportunities. Engage with a range of practitioners from young innovators to pioneers in the field as we discuss a variety of topics to help the inspired clinician thrive.

[MESSAGE]

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[EPISODE]

[0:01:23] MBH: Welcome to this episode, Keys to Evidence-Based Practice for the Multitasking SLP. I am your host, Mary Beth Hines. I am honored to have a co-host for this episode, fellow speech-language pathologist, Renee Garrett. Before we get started, we have a few items to mention. Here are the financial and non-financial disclosures. I am the host of Keys for SLPs and receive compensation from SpeechTherapyPD.com. No relevant non-financial relationships exist. Renee Garrett is the co-host of this episode. She is a paid employee of a large health system in the Commonwealth of Virginia. She receives compensation for this presentation from SpeechTherapyPD.com. She is the Secretary of the Communication Disorders Foundation of Virginia. Dr. Stacie Raymer receives compensation for this presentation from SpeechTherapyPD.com. No relevant non-financial relationships exist.

Our learning objectives for today are to explain the steps in a systematic review and its importance in evidence-based practice, define meta-analysis and its role in evidence-based practice, and identify three resources to access systematic reviews to guide evidence-based clinical decision-making.

[0:02:40] RG: Now we welcome our guest today, Dr. Stacie Raymer. She is the Graduate Program Director of the Masters in Speech-Language Pathology Program for the Department of Communication Disorders and Special Education at Old Dominion University. For the past 40 years, Dr. Raymer has been engaged in research to optimize rehabilitation outcomes in neurologic communication disorders, particularly those with aphasia following stroke.

Her work has been supported by the National Institutes of Health and the Department of Defense. She has published more than 75 papers and given hundreds of presentations nationally and internationally. Dr. Raymer is the past president of the Academy of Neurologic Communication Disorders and Sciences and is a fellow of ASHA. Welcome, Stacie. We're so happy to have you on Keys for SLPs to discuss an important topic for the busy SLP, evidence-based practice.

[0:03:33] SR: Thanks, everyone. Thanks for inviting me.

[0:03:36] MBH: Well, we're so happy that you're here. Renee, that's fun. A little fun fact, Renee and Stacie have known each other for a long time. Do you want to tell us a little bit about that?

[0:03:48] SR: Who gets to tell? Renee? Well, how about this way? You say it, Renee.

[0:03:53] RG: Okay, Dr. Raymer was my Ð

[0:03:54] SR: See, she did it.

[0:03:58] RG: She was my Ð not only my professor and academic advisor but also my graduate thesis supervisor. She gave me the opportunity to complete a 75-plus-hour research-based political thesis project with her. I was very grateful for that because it was a wonderful experience and definitely a learning experience. Then we have had interactions throughout both of our careers because I have taught at Old Dominion as adjunct faculty. Then we have a love of Old Dominion monarch football and other athletic programs and have served on the Communication Disorders Foundation of Virginia now together. It's definitely been a full circle moment, I think, for me.

[0:04:42] SR: Right. You've taught me a lot. In recent years, I rely on you, because you're out there in the trenches and I'm in the ivory tower and have forgotten probably more than you do every day.

[0:04:56] RG: Well, if it wasn't for your research, I don't know about how much I would be doing. So, thank you for everything that you've contributed.

[0:05:03] MBH: Well, thank you both. It's so fun to have a professor-student relationship and to have you both here after so many years ago, and so many years working together since. Let's dive in, Renee. Take it away.

[0:05:19] RG: Okay. Stacie, will you tell us about your career journey and how you merged your roles as a military spouse and speech-language pathologist?

[0:05:26] SR: Well, and that was one of the reasons Renee and I had always connected a lot as well, as we have this military background. I've got tons of students at Old Dominion University who have a military connection because we're just a couple miles from the largest Navy base in the world. The way I connected to the military was I went to graduate school at the University of Florida. I left my home state of Wisconsin and went to Florida, which was really delightful in January. Then happened to fall in love with this nice Navy officer, and onward to the military we went within a couple of years.

My intention when I went into speech pathology was to be a school-based therapist. My sister is deaf. That's when I learned about speech therapy. I had to go with her to the speech therapist in our little town in Wisconsin. I said, ÒI want to do that.Ó Well, so I went to the University of Florida. Then, fortuitously, they were looking for a couple of people to do a practicum at the VA hospital. I said, sure, I'll do it. I went down and I met Dr. Chick LaPointe, who at the time was at the VA in Gainesville. He happened to also be a Green Bay Packers fan, like me. I was very far from home. But he introduced me to aphasia and was my first mentor in aphasia. I just liked it. I liked it a lot. I really got along with the gentleman.

Anyhow, that launched my Ð I took a complete detour from what I intended to do in speech pathology. Then the military took us, let me see. When I finished my master's degree, my first job was in a school. Then I got married and we moved, and my second job was in a school. I have this interesting school experience in my background. Then I went straight into a Ph.D. program at the University of Maryland and then eventually, to the University of Florida where I finished, because the Navy moved us again. I finished my Ph.D. at the University of Florida. I definitely associate more as a gator.

You could see, it took a lot of flexibility to be able to make this all happen. It took a lot of miles of driving. I remember when we moved to Norfolk 27 years ago, we opted to live in Virginia Beach, which is a about 30-minute drive in traffic from campus. Everyone thought I was so far away. Well, I was used to driving an hour and a half every day with little ones, so 30 minutes was just normal. It took a commitment. I just liked it. I liked the people and kept going.

Aphasia became my life and my career as I rolled with the Navy a couple of times. I did a postdoc at the University of Maryland Medical School. Then I did another postdoc down at the University of Florida, again, because the Navy brought us back to Florida. Throughout that, my aphasia research career was really beginning to grow. It wasn't until I got here and received a Ð there was a faculty position at Old Dominion. The stage of my husband's career was that he could very likely end up in Norfolk, so I applied. They took a risk, thinking that I would be gone in three years. 27 years later, we're still here because my husband took a series of Norfolk jobs and then retired in Norfolk and still works for the Navy. 

That's only the first question, but that's the background. I mean, it took a lot, but eventually Ð and I've seen this happen a lot of times. It happens to be that often a woman, a spouse, takes a job in a new city, and you may not have the job that you hope for, and then something comes up. You end up having a career, and it thrives, and you get to make a contribution. It happened for me. I was very fortunate.

[0:09:50] RG: I think that's another way we also connect is because my husband was also Navy. When I went back to graduate school, my dad actually had had aphasia after a stroke when I was in my mid-20s. Interestingly enough, the month after I started my graduate program, my husband was deployed and my dad passed away. We always had these connections through the military, but also through just being an adult learner with children at home that we were responsible for the kids, too. Then I was also a partial caregiver for my dad. Yeah, it was a very interesting time.

[0:10:26] SR: I remember those times. I remember you in the clinic work room. Those were some challenging times, weren't they?

[0:10:32] RG: Yeah, very much. But, also, gave me a why and a purpose, and I'm still here.

[0:10:37] MBH: You certainly both exemplify multitasking SLPs in many ways.

[0:10:43] SR: Well, yeah. It's really being a military spouse and your husband's gone. Regardless of whether I'm in a university or working, if I'm working in the school, regardless, we're juggling a lot when the ship's away, or when our spouse is away for whatever branch of service. Tonight, we're talking about evidence-based practice. I suppose, I need to get us to that and I mean, how did that turn out?

[0:11:07] MBH: We sure do. IsnÕt it fun just to chat all night long?

[0:11:11] SR: No, it's easy to chat.

[0:11:13] MBH: But we do need to get into some learning objectives, right? Stacie, what do you think are the keys to evidence-based practice?

[0:11:20] SR: Well, and what I was going to guide us to is, because I want to put in a plug for how I even got to this piece of my career, because I was really involved in Special Interest Group 2, back in the Õ05 to Ô010. Around 2006, ASHA really, in medicine, evidence-based practice was being discussed before 2000. ASHA really was putting some money behind some initiatives to create platforms, to provide evidence to practicing clinicians. Because evidence-based practice, as you all know, is partly what our patients want, the client preferences. It's partly our professional expertise. But the foundation for those is research evidence.

ASHA was going to work on this series of systematic reviews. I was on the front end with Leora Cherney and Janet Patterson. We actually did the first ASHA systematic review, because they were launching this evidence-based practice platform.

[0:12:39] MBH: Did you say that was 2006?

[0:12:42] SR: Well, in 2006 is when we were doing the work, because the paper, our first paper, came out in 2008, but we were doing the work back then. Now, you look at Ð because I'm rethinking to the Practice Portal, and there's just so much. Well, that didn't exist in 2006. It was a vision that these folks at ASHA, who have worked very hard, have just done a phenomenal job bringing that to all of us. It's a resource that's so rich for every practicing clinician, no matter what your interest is, every area of speech pathology and audiology. That's the intro to what is evidence-based practice.

Okay, so you know, as a practitioner, I'm trying to access the research, because the key to evidence-based practice is accessing research. Well, there's hundreds of studies that are done. You lose access to a professional library, right? How do you do this? This wonderful resource that can help evidence-based practice are systematic reviews. A systematic review is a research endeavor where a group of researchers asks a specific clinical question. Often, we hear the phrase Ôa PICO questionÕ. That stands for population, intervention, the comparison intervention, and then an outcome.

To answer that question, you have to scour the literature. That's a key to a systematic review. A systematic review isn't just a literature review. I write literature reviews all the time, but a systematic review is intended to scour all of the literature that could potentially answer a specific question, because some studies may have one finding, and other studies may have alternative findings. The purpose of a systematic review is to put it all together in as unbiased a way as possible to then see what's the weight of the evidence in the literature.

It's a rigorous research endeavor, if done properly, that then gives a clinician confidence that what they're reading, this paper that is summarizing some of the literature, is providing them with an unbiased view of this treatment approach, or you can do it about a diagnostic approach, whatever, a screening tool, because you can ask questions about all those things.

[0:15:32] MBH: Typically, with a systematic review, how long should you expect a systematic review to take?

[0:15:37] SR: If I was doing one, it takes several months, because it takes a while to find the literature, and then you have to Ð It depends what research question, or keywords you ask out of a search engine. You go to search engines like PubMed, or sometimes Google Scholar, whatever, there's a number of search engines. Finding the literature is a big first step. Then, often, you find dozens of articles that you have to start reading. Then, in a rigorous systematic review process, there's at least two people doing all the reading, so that the two people independently could be reading, making decisions, extracting data, and then you can make sure that there's agreement in the decisions that are being made and the data being extracted from literature.

That's a very important step in assuring non-bias, because otherwise, I could just pull out the good stuff from my papers, right? No. You're encompassing the whole literature and multiple people reviewing. I hope what you take away tonight is to think about, okay, because there's all kinds of systematic reviews now. What should I be looking for when I'm reading a systematic review to know that it's a well-done systematic review? That's one of the easy things. Do they talk about multiple readers, multiple reviewers, pulling data out, and then even reporting how consistent those readers and reviewers were? Those are elements to a strong systematic review. 

Ultimately, there are ways to take this systematic review to pull together all the research. One of those ways is to do a subjective overview of the research. But the other way is to do an objective combination of the research results from a number of studies, and that's called a meta-analysis. Generally, a systematic review is a large review of the literature of every article that could be found with a general descriptive. That's the right word that I want to say, a descriptive summary of all those findings. A meta-analysis takes some of those individual findings on a tool that's the same and combines them into one statistic.

In aphasia, a lot of studies look at word finding. They might use a Boston naming test. I can use the Boston naming test results of study one, study two, study three, put them all together, and now I've got an even stronger representation of the literature and stronger evidence. If the statistic shows that it's a positive finding, that the treatment that I'm providing is better than just spontaneous recovery alone, or some other standard treatment. But the premise of meta-analysis is combining results when there are similar outcome measures, similar metrics.

Could I have a Western Aphasia battery score? Yeah, if there's a study Ð One study used Western Aphasia battery, another one used Western Aphasia battery. You can combine those results and see the meta-analysis is an analysis of multiple analyses.

[0:19:20] RG: Then who would be the person Ð Is there typically a lead investigator that would be concerned with inter-rater reliability and intra-rater reliability? Is that part of this?

[0:19:29] SR: Generally. Yeah. I mean, it could be done in any number of ways. Sometimes it's the lead is directing the flow of traffic and a couple of other people are involved in that piece of the puzzle and then they might do the reliability metrics. It could be done in any number of ways. Often, you see, there's a number of people, number of co-authors in these review papers, because you're just reading. But you could be reading dozens of papers, and that takes time that in the context of all the rest that you're doing in your multitasking day, right, trying to fit this into the calendar.

[0:20:16] MBH: Exactly. Now, how does an evidence map fit into the systematic review?

[0:20:21] SR: Oh, yeah. Well, the way ASHA has certainly done evidence maps is they've coalesced every systematic review they could find on all kinds of topics within speech pathology. You can click on a topic, let's say, cleft palette, and the evidence map would link the reader to studies, systematic reviews. Sometimes you'll see papers that are called practice guidelines. That's a step beyond the systematic review, where they make some very strong clinical decisions.

Those practice guidelines also get added to evidence maps. The evidence map is just a coalescence of all these resources: systematic reviews, practice guidelines, and other kinds of general introductory material that clinicians Ð it's just full of helpful information for clinicians who are trying to stay on top of the most recent thinking.

[0:21:25] MBH: Thank you. Okay, if we're not overwhelmed already. No, I'm kidding. Okay, let's talk about some resources. One is ASHA. Can you tell us again, for the multitasking SLP, so they don't have to look it up? If you went to the ASHA website, where exactly do you go to find the systematic review?

[0:21:46] SR: Oh, it's on the top right.

[0:21:48] MBH: Okay. Okay.

[0:21:50] SR: It's resources for, like I said, I have a number of things open on my desk, but that's not one I use it so often.

[0:21:57] MBH: That's okay. We'll go to the members section and go to resources.

[0:22:02] SR: You don't even have to log into the membersÕ section. It's under practice management. Yeah.

[0:22:09] MBH: Practice management. Okay.

[0:22:10] SR: Practice management is where you're going to find it. Then that puts you to the practice portal and evidence-based map, evidence maps. That is just a great starting point. I send my students, in fact, often in my aphasia class on one of their assignments, there's a case study project at the end, and they're required to include the evidence maps, because I want them to know this exists.

It shocks me. A lot of times I'll give talks at professional meetings and always ask people, "Raise your hand if you do use the ASHA practice portal.Ó Only a couple raise their hand, instead of everybody. It's the best value for the amount of money we pay every year. That's where you get your value from: the ASHA practice portal.

There's other places that you can find similar information. One that I really like, it came out of the folks in Australia. They created Ð it started being called PsychBITE and then they created SpeechBITE. It was the neuropsychology information, cognitive-communication information. Then they created SpeechBITE and BITE stands for something for intervention. I had it open earlier, so I could remember, but it's an acronym, the B-I-T-E. Speechbite.com is really helpful resource to look at. You can put in research designs that you're interested in, or just systematic reviews, and then it spits out summaries of some of these tools that have been published throughout the world, because these things go on all over the world.

Another really important one is the Cochrane Database of Systematic Reviews. That comes out of Great Britain. The Cochrane database, they have systematic reviews on every imaginable topic in medicine. If you're interested in heart disease, or knee disease or anything, but we're of course interested in stroke and aphasia, there's systematic reviews that have been done through Cochrane. You can find findings about pharmacologic treatments in aphasia and just general aphasia treatment. It's very rigorous systematic reviews. SpeechBITE from Australia, Cochrane from England, and ASHA from the United States. Those are awesome resources to get to some of the summarized systematic reviews.

[0:24:51] MBH: Well, thank you. Now, is the ASHA's systematic reviews in the practice portal, are they more of a United States focus, or an international focus?

[0:25:01] SR: Well, the premise of a systematic review is going to pull every paper possible. Most of the time, one of the inclusion criteria is that the papers are written in English. Most of the time because they're done by scholars whose first language is English. It's certainly biased toward English literature. What I see more and more is that in Asia, there's a tremendous amount of work coming out of the Asian countries. They're publishing some of their work in an Asian language, or an Asian journal, but there are tools to translate these papers.

Somehow, I can't remember what language it was, but translated a systematic review about a topic into English. It's not perfect, but it was a way to capture what's happening in the world and not just. These aren't just about the United States. These are about all research that takes place on a given topic.

[0:26:11] MBH: Excellent. All right. Okay. Renee, do you have any other questions about evidence-based practice?

[0:26:19] RG: No. I just know that Australia has been doing a lot of aphasia research ever since probably even before I was a student. The validity of what they've been doing and how they've compiled everything, I think, is pretty strong. I used the Cochrane Database when I was a student as well. I'm fortunate that I knew what those things were and have been able to use them throughout my career because it definitely gives you a better way to purview the literature. When you're a practicing clinician, you're not necessarily in an evidence-gathering role as far as a researcher.

It's a little bit more of a challenge to go through all these papers and try to figure out, okay, like Stacie said, what is this research, as far as validity goes? How is this being measured? How many people are looking at it and looking at the overall design of the study to make sure that that's also valid?

A lot of those things, if you didn't learn that in school, you may not know that. You see a paper and you cannot jump on it, because you think, ÒOkay, this is new and novel,Ó but we have to have that back review from people who are doing the research and have more extensive training on how to analyze that. It's a segue for us as clinicians in the field to look at what the academic world is doing and connect the two via those resources. I'm so grateful to have that experience as a student and then also, to hear how that's grown throughout the years.

[0:27:50] SR: Something you just said, Renee, that really nicely takes us to talking about constrained and induced language therapy, which is the example that we want to talk about today. Back in 2000, a paper was published by Ð it was a German paper, but Paul Vermeuller was the first paper and it was published in the Journal Stroke. The Journal Stroke is not read by speech pathologists. That's read by the doctors. It was about this approach, constraint-induced language therapy that was based on a constraint-induced movement therapy that had been developed in physical therapy, which was based on some basic animal research.

The premise is that if you don't lose it, or if you don't use it, you will lose it. There's this balance in speech pathology, where if you only do compensatory strategy and training, there's potential for our patients to get better in their language abilities. That's if they use their language. Anyhow, the 2000 paper came out in Stroke. Before we knew it, it got a lot of press and clinics around the United States. I don't know other parts of the world. Clinics in the United States were offering constraint-induced language therapy immediately.

There are a lot of rich people who get aphasia and are willing to pay as much as they need to pay to try to improve because it's just such a tragic situation. These CILT clinics were popping up around the United States. Right around then is when ASHA was creating this endeavor to start doing some of their own systematic reviews. In Division II, we said, ÒHey, CILT is a potential topic. We think we know there are these clinics popping up. We'd be willing to do a review of the literature of CILT and do that first systematic review to help clinicians know whether this was worthwhile. Should they be doing this CILT work?Ó

Constraint-induced language therapy has a couple of principles that are at play. It's usually done in the context of a small group, or a dyad of people with aphasia, with the clinician prompting and supporting where the people with aphasia engage in some language activities, you could call them language games. One important premise is that the patient must use verbal responses. They're not supposed to use compensatory responses. Use verbal responses. Then moreover, the intervention was provided very intensively. The word intensive means a lot of different things. For right now, what I mean is in one week, the patients were seen for 12 hours. That's three hours a day, four days a week, 12 hours.

In fact, in the Paul Vermeuller paper, it might even have been five days a week for three hours. I think that's correct. Five days a week, three hours, so that's 15 hours a week for two weeks. 30 total hours. Well, how many of you have that possibility? It was a forced language treatment done very intensively. All right, so that's the treatment. There were, after the Paul Vermuller study, there began to be a series of original research studies published.

By 2006, 2007, when we were doing this work, we found five original studies that had been done around the world. That literature has grown and grown and grown. We did our systematic review that was published in 2008. In 2010, we added to our systematic review. Let me see, I have this interesting table that I wanted to refresh my memory.

By last year, there had been about six different systematic reviews that had been conducted. It turned out, three of them were systematic reviews, descriptive summaries of the literature. Then the three most recent reviews were meta-analyses because now there's more data and more studies using more common metrics. There have been six systematic reviews. Across those six systematic reviews, there are dozens of original papers that published constraint-induced language therapy evidence.

There's no way that you could keep on top of that. Dozens and dozens of papers. But heck, it would be hard enough just to read six systematic reviews. That's where the literature has gone. We have a paper that's just coming out in AJSLP about systematic reviews of constraint-induced language therapy. The reviews themselves, they've gotten better and better, because there's literature to guide people doing systematic reviews. The rigor of systematic reviews has certainly improved in the last five years in particular.

What we see in CILT in particular is that when compared to a treatment that is a standard treatment, maybe 30 hours of a standard treatment twice a week, for two hours a week for 15 weeks, yeah, it appears that the intensity piece of the puzzle is very important. I mean, getting more is better. Then the other piece of the puzzle is the forced language, is that the important component? One of the recent systematic reviews, it's probably my favorite and it's done by an Australian group led by Pierce, Pierce et al. My friend, I think Miranda Rose is one of the co-authors on the Pierce et al paper. They compared constraint-induced types of therapies that are verbal-only therapies to a multi-modality type of therapy for aphasia. Because there's plenty of aphasia treatments that encourage verbal production and some Ð look at me, my hands are moving, communicative gestures, or drawing, or writing, whatever. Multimodal types of treatment.

The Pierce papers gives some pretty convincing evidence that it's the intensity part of the story that's very important. Whether it's forced verbal production treatment, or a multimodal treatment, if it's done in an intensive way, you get your best outcomes. Now the literature primarily is about language test outcomes. A Boston naming test, or a Western aphasia battery, or some kind of general aphasia battery. Auditory comprehension. Because there's quite Ð in this diet or group format, the people with aphasia are not just speaking, they're also listening. We do see comprehension improvements for people who participate in constraint-induced language therapy.

What we really want to know is, does this make a difference in people's lives? The descriptive reviews generally shows, there are communication rating scales that people will provide or examine, some connected speech measures. Descriptively, it seems that intensive treatment improves production, regardless of whether it's done with forced verbal or a multimodal type of treatment. There needs to be more evidence to be able to do a meta-analysis, but there's just the outcome measures are all over the place.

No one has attempted a meta-analysis of some of those connected speech measures, or rating scales. That would be the best evidence, someday to know some of these patient-reported outcomes that these treatments really are changing people's lives in patient-reported outcomes. That would be the best evidence. That'll be the direction of the future, I hope that more studies will look at some of those outcomes, not just these language scales, which aren't as meaningful.

[0:37:18] RG: Well, and to let the participants know who are watching this and listening to this, I'm thinking about me having worked in inpatient rehab, where we got to see our patients for an hour a day, five days a week. Then versus outpatient, where we're constrained a lot by insurance. It's difficult because a lot of our folks are really in need of having more intensive therapy for whatever reason, if it's an insurance issue, a transportation issue, or just geographic availability. I think that would be interesting to see, too, where are they getting this intensive treatment? Is it specifically an aphasia connection recovery type center, or intensive? I know, wasn't it University of Michigan has the Ð

[0:38:00] SR: They do have an intensive program.

[0:38:02] RG: Right, where they go for several weeks and spend the time there.

[0:38:06] SR: Yup. And Leora Cherney at the Ð oh, they changed the name of the lab.

[0:38:12] RG: Yeah, the AbilityLab, it used to be.

[0:38:14] SR: The AbilityLab in Chicago is another. In Montana, Cathy Off does some intensive groups. I mean, all over the United States, there are clinics that are popping up that allow some opportunities for these intensives. For the regular practicing clinician, you're right, Renee. We're constrained to twice a week. We got to solve that problem in other ways.

[0:38:42] MBH: Well, if you think about healthcare equity, it sounds like, you can correct me if I'm wrong, if insurance is not covering the intensive therapy, you either have to be going to a clinic. If you don't have the means, you have to be going to an academic clinic, where it's paid for by the university or there's a minimal charge, or you have to be able to afford this intensive therapy. Do you have any idea, like a private clinic, how much two weeks of CILT program would be?

[0:39:13] SR: I have no idea. I'm sorry. I don't know. Because for me, I try to Ð I'm going to try to solve it in another way. Given the constraints of insurance, we got to be doing homework, computer, there's plenty of software programs, computer access. Now, but still brings up the whole health equity issue.

[0:39:35] RG: Because not everyone has access.

[0:39:37] SR: That's right. More and more people do have some of these resources in their homes, but certainly not everyone. We have to do whatever we can to get resources to folks. Heck, I think about my dad a year ago, had a minor stroke. God forbid, it had been a major stroke, he's in a little town in Wisconsin. He's lucky. They do have a community hospital and he could have received some therapy, but it's not the same as some major medical center. It's not quite the same.

[0:40:10] MBH: I have a question. How does the systematic review account for variability in the studies? Let's say, one CILT program had two people and a therapist and one program had six. Are they in the review? Is that being accounted for?

[0:40:27] SR: Usually, not in a systematic review, because that's very descriptive. Yes, in a well-done meta-analysis. What happens is that a study that had more participants gets a higher weight than a study with fewer participants. In a meta-analysis, sometimes you'll see this graphic where, in their tables of the published paper, they'll list all the individual studies that were part of this overall analysis. Then they'll have these little diamonds that are either toward zero, or toward one. You want them to be away from zero, showing, okay, this treatment has an effect.

To the extent that the size of the diamonds and to the extent that diamonds do not overlap zero, that's what you want to see. Then usually, there'll be a concluding diamond. There'll be a final summary statistic. That has encompassed exactly what you're talking about, Mary Beth, in terms of the weight of the evidence of some studies, a bigger study contributed more to the final statistic, to the final analysis. Yes.

[0:41:51] MBH: The number of participants in the study, but also the ratio of therapists to participants.

[0:41:58] SR: No one has really looked at that. I can't think of any studies that have talked about the ratio. Yeah, I don't know.

[0:42:07] MBH: In general, most of these CILT programs are, how many participants would you say?

[0:42:12] SR: Like four in a room. Four in a group. Yeah, three or four. I've done it with two and I loved it with two. It was a great experience in a dyad. I've seen a lot of times four around a table all working together.

[0:42:30] MBH: Well, sounds like that might be another study here in two to four.

[0:42:34] SR: Yeah. Well, there's all kinds of questions, but the difference in the effect is probably so small that you couldn't find the effect. It would take a very large study to tease apart that kind of a question.

[0:42:46] MBH: If you think about the intensity, though, if you have twice the number of participants, you're not going to have Ð your participation is going to be divided.

[0:42:55] SR: Exactly. You have less opportunity to talk. Yes. Yeah, so that's a fair Ð That's a different element of intensity. That's very fair. Going back to Ð in the context of the whole, the whole interchange, there's comprehension Ð while the other person's talking, you're working on comprehension. There's a lot happening in a room when these kinds of sessions are taking place.

[0:43:24] MBH: Well, how exciting. I did not realize that ASHA really started this, because I took some years out of the field to raise my family. I didn't realize it was only 2006 with the first push for evidence-based practice in a systematic review. That seems amazing to me, because correct me if I'm wrong with my math, that's 17 years ago, right?

[0:43:48] SR: That was the first that ASHA put money behind doing systematic reviews. Because certainly, they valued evidence-based practice well before that. Earlier, we mentioned ANCDS, Academy of Neurologic Communication Disorders and Sciences. For adult neuro people, ANCDS was the first one engaging as an organization in systematic reviews. I can't remember the first one. The first one was a dysarthria review by Kathy Yorkston. I forget the year on it. It was way back in the 90s. It was by 2000, they were beginning to put out and publish a number of reviews.

Because shame on me, that is another resource, ancds.org. You can access a list of the reviews that have been done through there. Probably many of the papers you've read in various journal articles, oh, yeah, those were done under the auspices of ANCDS.

[0:44:51] MBH: Well, thank you for sharing that. We'll just add that to our learning objective. Yeah. Thank you. All right. Well, Renee, do you have any other questions regarding the CILT Systematic Review?

[0:45:05] RG: I do, actually. One of the things that I was interested in knowing was how the connected speech is measured. Are the studies looking more at MLU? Are they looking more at a narrative analysis, combination of things?

[0:45:20] SR: Any of those things are being done. In aphasia, a lot of times, they'll use metrics called correct information units, or content units, or get at some of the linguistic analyses. It's just all over the place across papers. That's why you don't see good meta-analysis of connected speech outcomes because there's just so many possibilities. Indeed, that's what people are doing. I mean, if people, if everybody did a rating scale, a common rating scale, okay, that's easier. Then we could begin to put those together. It's really very cumbersome to try to do a meta-analysis of connected speech metrics, because they're all over the place.

[0:46:09] MBH: Good question, Renee.

[0:46:11] RG: I had another thought.

[0:46:12] SR: Okay.

[0:46:13] RG: Is there any thought or inclusion also at any of the systematic reviews about communication partner training? Because under the life participation approach for aphasia, that's something that I've tried to fit. Well, and also, because I was a family member, part caregiver for my dad, that was something I felt like, we really needed was communication partner training. That was back in Õ97 when my dad had a stroke the first time. Yeah, I just wondered if it was more literature-driven now to include those types of things and their role in the intensive approach?

[0:46:50] SR: Yeah, actually with Nina Simmons-Mackie and Leora Cherney, Audrey Holland, we did a systematic review of communication partner training. That review was sponsored through the academy, let me see, of ACRM. American Congress of Rehab Medicine, because they do. Probably, many of you are familiar with the Cogcom systematic reviews that they're very Ð they covered everything in this one paper, including a section on aphasia. Those were supported through ACRM. Leora got ACRM's interest and we did the communication partner training. I think that paper was 2013.

There is quite a literature about communication partner training. It was a systematic review and descriptive summary of what was happening in that literature. The interesting thing in that literature, you know, I'm getting old. IÕm getting really old, so I forget, but the communication partner training literature shows that people with aphasia improve their use of communication strategies. Their language doesn't improve. The language measures don't show positive outcomes, but their communication measures certainly do. That's what you're working on. You're not working on improving talking, you're working on improving communicating.

That literature definitely shows a positive benefit of training communication partners, because communication partners don't know how to talk to someone with aphasia initially, or how to draw out the best in someone with aphasia. See, so there's systematic reviews in every area. We just happen to pick CILT as an example to talk about evidence-based practice. Definitely, that's another one to look at. That was in the Archives of Physical Medicine and Rehabilitation quite a few years ago now already.

[0:49:05] RG: You do have a question in the chat that says, ÒCould you provide a quick example of your forced language in the dyad?Ó

[0:49:11] SR: Oh. Well, so the patients are prompted. A lot of times you'll see where the dyad people, they have cards. It's like a barrier situation. One patient has some cards and another patient has some cards, and it's sort of a Go Fish game, where they are required to use some kind of a verbal template, something like, do you have the red car, or something that? Do you have the blue, blue bird? I'm just pulling those out of nowhere. Typically, there's a template. They have to use a verbal request. Then there's a response by the partner, ÒNo, I do not have a red car.Ó

There's this interchange, typically using some kind of template. The template could be on a card, or the clinician is at the side guiding the patient, queuing the patient like we always cue the patient to the verbal production. They're queued as best as they can. Then they go back to the beginning and try to provide the whole utterance once they struggled through producing the utterance, then they go back to the beginning and say the whole utterance once again to the best that they can.

This repeated work, I mean, my personal experience was with a clinician who was doing a research study in the Richmond area. I was assisting her and I coded all of her video for her study. From beginning to end, the patient, especially with moderate BrocaÕs aphasia, really improved production by the end. The person with more severe BrocaÕs aphasia improved, but not nearly as much as the person with a moderate. It could really push this person to be producing much more complete sentences, because it's about producing complete grammatical sentences as much as possible, in the constraints for each individual in the group. Because some people in the group, maybe their goal is just to produce a single word, or a two-word phrase, and someone else in the group, their goal might be to produce a full question, grammatically correct question. Using some kinds of template cards, or prompting queuing is what happens in a session. I hope that helps to explain a little bit.

[0:52:00] MBH: Yes. Do we have another question?

[0:52:04] RG: I answered that one. It was just, what are the three resources speech by ASHA in the Cochrane database?

[0:52:10] MBH: Perfect. Thanks. Thanks, Renee.

[0:52:11] RG: You're welcome.

[0:52:12] SR: Yes. Thank you.

[0:52:14] MBH: All right. Well, as a reminder to our participants, you can put your questions in the chat box, and Stacie will be happy to answer them for us. Or if you have a question for Renee or me, we'll be happy to answer them as well. Stacie, you've had such an exciting career. What are your future projects or plans?

[0:52:37] SR: Well, unfortunately, well, 10 years ago, my human subjects research really was curtailed, because I became a department chair for seven years. Then we had COVID. Really excited. We're moving from a college of education to a college health science this summer. Then I'm going to become department chair once again. My human subjects research just is not getting relaunched. The whole, what I've been doing, like the paper that I just referred to earlier, we're doing some work, looking at systematic reviews across aphasia on a number of topics.

Last week, we had a clinical aphasiology conference. It was up in Atlantic City. We did a poster and we'll be working on a paper, but it was about transcranial direct current stimulation. TDCS. Another one of those interventions that, and it sounds really sexy, is putting something on someone's head and providing some kind of a signal and then doing therapy. That sounds really, really awesome. There are dozens of studies of TDCS all over the United States looking at its effects for aphasia. And there are 16 different systematic reviews that have been done about TDCS in aphasia. We're preparing a paper about that literature. After that, I'm not sure.

[0:54:11] MBH: Well, congratulations on becoming the chair again and moving the department to the new college. That is very exciting. Another thing that was exciting about that, I believe that Renee became the last fellow. Can you describe that to be named for the former college? Renee, can you tell us a little bit about that?

[0:54:32] RG: Which part, the part where I was trying not to throw up? No, it was a very unexpected and huge honor. There's been, I think, the number was something like 42,000 graduates that have come through the Darden College of Education and Professional Studies. There's six divisions in the communication sciences disorders, and special education is one of those divisions. I was selected by my former professors, which is very overwhelming and humbling and exciting all at the same time.

The other really cool thing was that all six divisions had a female that was selected. We were a group of all-women professionals from each division. I'm not sure that's ever happened before. I thought that was pretty amazing just to be a part of that. Now, I'm the last one for our division, so.

[0:55:29] SR: Yeah, and we don't know in health sciences if they do something like that. Every other year we would select an alumnus that had made outstanding contributions. It was a no-brainer for it. I mean, look, Renee's here right now doing this work, but she also is a leader in the state of Virginia and we wanted to recognize that.

[0:55:50] MBH: Well, congratulations again. Let's go back to what you just said, though, about transcranial direct communication stimulation. Do I have that Ð

[0:56:00] SR: Yeah, that's a whole different topic.

[0:56:02] MBH: Okay. I know it's a whole different topic, but since we have a couple of minutes, I just wanted to ask, what is this? Is it magnetic stimulation?

[0:56:10] SR: No. It's just an electrical signal. There is something called TMS, transcranial magnetic stimulation. Those are very large units and very expensive units. They're pretty much only in a research enterprise doing TMS research in aphasia. It seems like, when you put a magnet around someone and then you engage them in therapy, the premise is that you're trying to get the neurons to be more ready to fire, more ready to connect. TMS, the evidence is pretty good in aphasia that it improves outcomes beyond just their behavioral therapy alone. But it's too expensive.

Renee is never going to have one of those units where she works. But TDCS, it's just an electrical signal that Ð thereÕs two different stimulation components. One is anodal and one is cathodal. There's any number of arrays where these are Ð but this is an electrical signal. There's just a band that has these little units in the band, and you can get them for several hundred dollars. People are buying them for themselves. Rich people with aphasia, they go buy one or clinicians are buying them.

The question is putting this on and then engaging in behavioral speech therapy, does it help compared to just behavioral speech therapy alone? The TDCS data are not quite as impressive. The right studies are now being done, because in our work, there were 72 individual research studies that have been taking place all over the world. Let me tell you, the Asian countries are doing this like crazy. The outcome that you see the best data for is that in a picture naming paradigm, a person who has TDCS, plus therapy has a better outcome than just therapy alone.

What we were talking about last week is, is that sufficient? Does that really matter for your patient, Renee, that you're going to see in rehab? Is that enough? Virtually, none of the TDCS studies are asking about connected speech, rating scales or communication participation metrics, none. They're all doing a general aphasia test, a word finding, but the proof of concept is done. It's time to ask, does it change communication? There are people in the United States who are doing some studies to try to answer that question. Until we get a little bit of that data, I'm not planning to put these on my patients. But there are people who are.

[0:59:33] MBH: Is it a difference that makes a difference?

[0:59:35] SR: That's exactly right. Is it a difference that makes a difference? That's the perfect way to put it.

[0:59:40] MBH: Well, thank you. Okay. Well, just a reminder, we can ask a few more questions if you like, but we have a great question for Stacie that we talked about ahead of time. You've had such an amazing career and have worked for over 40 years in our profession. What is your advice to people who are just starting out in the field? I know we have some people who listen, who are just, they haven't even started in the field. They're just interested in the field. We have some students and grad students and new clinicians. To all of those people, what is your advice?

[1:00:16] SR: You have to be a lifelong learner. In the beginning, there's so much to know and there's so much to continue to learn and know. In the beginning, you have to give yourself grace. I remember decades ago, trying to read everything and feel like, I'm never going to catch up. Then one day I realized, okay, I have a body of knowledge. But I'm keeping an eye on what's new. Give yourself grace in the beginning. Keep learning. Then, always have an attitude of ÒI want to learn more.Ó That's why you go to annual meetings. That's why you go to the state meetings, because there's always more to learn. I don't know, that's the main advice.

[1:01:04] MBH: Well, I think that's excellent advice. Give yourself grace and keep learning.

[1:01:08] SR: Yeah.

[1:01:10] MBH: I think I need to remind myself of those two things every day.

[1:01:13] SR: Yeah. Let me tell you, if I had to go and see a child with an articulation or speech sound disorder, because hey, I learned that they don't call it articulation disorder much anymore, they say speech sound disorders. I'd be terrified, right? I'd be terrified. Give yourself grace. No matter how much experience. You all are experts in things that I'm not an expert in.

[1:01:39] MBH: Well, and continuing to learn, I think, is fun. I know, Renee, we've had a lot of fun on these podcasts and webinars together. I think there's a great learning community of continuing education right now. I think the internet has really added to the fun of learning.

[1:01:56] RG: Yeah, I agree. It's always nice to have a phone a friend card, too, and have a network that you can call back on your colleagues that are in different arenas and different settings in academia, or good resources, because we can reach out to those folks and maintain that network and build that professional relationship and emphasize that to students and the new people in our profession as well because I think that's a big part of what I've done throughout my careers is do that.

[1:02:27] MBH: Yes. All right. Well, we are nearing our time. Is there anything that either of you would like to add?

[1:02:33] RG: No. Thank you, Dr. Raymer, Stacie for agreeing to do this.

[1:02:37] SR: My pleasure.

[1:02:38] MBH: You can do it, Renee. Call our guest, Stacie.

[1:02:44] RG: Thank you so much for agreeing to do this. I know it was a big ask when I reached out. Mary Beth was onboard for the day. We talked about it, but it was an honor to have you on tonight.

[1:02:55] SR: Well, it was fun. It was my pleasure.

[1:02:58] MBH: It was fun. It was an honor to have both of you. I love having a co-host to stir things up. Stacie, you gave us so much information. We really appreciate it. There was a question about the notes. There will be show notes for this. There's not a handout, but there are show notes that will come out after this is edited. Thank you very much to our participants and thank you, Stacie. Thank you, Renee.

[1:03:21] RG: Thank you. Bye.

[1:03:22] SR: Bye, everyone.

[END OF EPISODE]

[1:03:23] MBH: Thanks for joining us here at Keys for SLPs, providing keys to open new doors to better serve our clients throughout the lifespan. Remember to go to SpeechTherapyPD.com to learn more about earning ASHA CEUs for this episode and more. Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.

[END]
KFSP 67		Transcript

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