1. Connective Solutions
21/08/2012
Evidence-Based Practice in Augmentative & Alternative Communication: How do you do it? What does it mean for Individuals who use AAC?  
Pammi Raghavendra. Ph.D.
Senior Lecturer, Disability & Community Inclusion, School of Health Sciences
Flinders University, Australia
ISAAC-Israel Annual National AAC Conference, Tel Aviv
8 June 2014
All day workshop
Emma Grace

2. EBP Workshop, Northcott, Sydney
2/11/2009
Workshop Outline
What is EBP?
What does EBP mean for individuals who use AAC and other stakeholders?
Steps involved in EBP – 7 steps
Asking a clinically relevant & answerable question
Searching for the evidence
Critically appraising the evidence
Collating & synthesising the evidence
5. Implementing the evidence into practice
6. Evaluating the use of the evidence
7. Disseminating the EBP process & findings
Facilitators and barriers to EBP
Practical Suggestions to implement EBP
Nature and extent of evidence in AAC
What can you do to add evidence to the AAC field?

3. EBP Workshop, Northcott, Sydney
2/11/2009
Evidence Based Practice
(EBP)
What is it?

4. Background to Evidence-based Medicine (EBM)
Archie Cochrane ( )
The Cochrane Collaboration
David Sackett (1914-)
Definition of EBM, Father of EBM

5. Evidence-based medicine
“the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”
Sackett et al., (1997, p.2)

6. What is Evidence Based Practice?
Definition:
“the integration of best research evidence with clinical expertise and patient values
(Sackett et al., 2000)

7. What is Evidence Based Practice in AAC?
Proposed Definition: (Schlosser & Raghavendra, 2004)
EBP is defined as the integration of best and current research evidence with clinical/educational expertise and relevant stakeholder perspectives to facilitate decisions for assessment and intervention that are deemed effective and efficient for a given direct stakeholder.

8. EBP in AAC Schlosser & Raghavendra, 2004

9. What is Evidence Based Practice? – Key concepts
Integration = joining / synthesis of best
research evidence
clinical expertise
stakeholder perspectives (patient values)
(Schlosser & Raghavendra, 2004)

10. Key concepts continued…
Best research evidence =
Data : current, verified and replicated
High internal validity
Highest level on hierarchy of evidence
Adequate external validity and social validity
(Schlosser & Raghavendra, 2004)

11. Key concepts continued…
Clinical expertise = reasoning, intuition, knowledge and skills related to clinical skills
Educational expertise = reasoning, intuition, knowledge and skills related to educational skills
(Schlosser & Raghavendra, 2004)

12. Key concepts continued…
Relevant stakeholder perspectives/values = viewpoints, preferences, concerns and expectations relative to the assessment or intervention
Patient/client = direct stakeholder ie direct recipient of any decision arising from the EBP process
(Schlosser & Raghavendra, 2004)

13. What EBP is not? Myths about EBP
EBP is impossible to implement because we do not have enough evidence.
EBP already exists
EBP declares research evidence the authority
EBP is a cost-cutting mechanism.
EBP is cook-book practice.
EBP is impossible to put in place.
(Sackett et al., 1997; Schlosser, 2004)
Best and most current research evidence is relative
Some practitioners do implement EBP
EBP in medicine/AAC definition-all 3
Not always true
EBP requires not only extensive clinical expertise but also skillful integration of all 3 aspects of EBP
some degree of EBP by all.

14. EBP Workshop, Northcott, Sydney
2/11/2009
What does EBP mean for an individual with complex communication needs ?
Individuals with CCN (their families)
Central to EBP outcomes, promoting adoption of effective interventions & preventing adoption of ineffective outcomes
Active participants in decision making
(ASHA, 2004)

15. What does EBP mean for a practitioner/educator?
EBP Workshop, Northcott, Sydney
2/11/2009
What does EBP mean for a practitioner/educator?
Best Practice
Use of EBP as a framework for best practice,
Promotes development of skills in finding, appraising and implementing evidence
Emphasises need for high level clinical & communication skills
Provides a framework for self-directed, life long learning
Ethical principle: To provide the best available services (assessments & interventions) to consumers & families
Practice-research gap

16. What does EBP mean for a service provider/ an organisation?
Best Practice at Organisational level
What do families think of using iPads/tablet technology for communication and participation?
What are the most effective post-school options for students with CCN using AAC?
Use of EBP as a framework for effective and efficient services
Facilitate/support to implement EBP

17. What does EBP mean for researchers?
EBP Workshop, Northcott, Sydney
2/11/2009
What does EBP mean for researchers?
Excellent opportunity to bridge research-practice gap
High priority clinical questions in diagnostics, screening, prognosis, intervention
Conduct high quality research
Disseminating research in way that can be used in practice

18. How do you do EBP? Adapted from Schlosser & Raghavendra (2003)
Asking the clinically relevant & answerable question
Searching for the evidence
Critically appraising the evidence
Collating & synthesising the evidence
Implementing the evidence into practice
Evaluating the use of the evidence
Disseminating the EBP process & findings

19. Step 1: Ask an clinically relevant & answerable question
EBP Workshop, Northcott, Sydney
2/11/2009
Step 1: Ask an clinically relevant & answerable question
Broad or general questions
provide background information
Systematic review
e.g.,
What are the potential barriers and facilitators to high-technology AAC provision and its ongoing use?
What are the attitudes toward Individuals who Use Augmentative and Alternative Communication?
What is the effectiveness of using iPads/iPods with individuals with disabilities?

20. PICO (Richardson, Wilson, Nishikawa & Hayward,1995)
Patient or Population/Problem
Intervention
Comparison or Control
Outcome

21. PICO To clarify the questions related to specific clients
To develop questions for Systematic Reviews
To identify the information needed to answer the question
To translate the question into searchable terms
To develop and refine your search strategy

22. Patient / Population/Problem
Characteristics of the population e.g age, gender, diagnosis, ethnic group etc
How would you describe your Patient/Population group?
Balance precision with brevity

23. Intervention Defining the intervention
What intervention are you interested in (be specific)?
Therapy, prevention, diagnostic test, exposure/aetiology

24. Comparison or Control
What alternative or other option are you comparing your intervention/assessment to?
Be specific
You may be comparing your intervention to another intervention, or to no intervention

25. Outcome
What measurable outcome(s) are you interested in? What are you hoping to achieve for the client?
Be specific

26. ELEMENT SUBJECT KEY WORDS P I C O
School aged children with cerebral palsy, complex communication needs
Child
Children
School aged, 12-13, primary school, transition, high school
Paediatric/paediatric
Cerebral palsy, physical disability, spasticity, hemiplegic, CCN, AAC, severe communication/speech impairment, I
Group-Peer training of high school students (workshops)
Peers, classmates, training, communication, support C
Visit by student with CCN plus training O
Increased acceptance, welcoming classroom, social networks
Social networks, friends, friendships,

27. Ask an clinically/service relevant answerable question using PICO
Group Work Activity 1
Ask an clinically/service relevant answerable question using PICO

28. PESICO template (Schlosser, Koul & Costello, 2007)
EBP Workshop, Northcott, Sydney
2/11/2009
PESICO template (Schlosser, Koul & Costello, 2007)
Person/Problem (P)
Person & problem
Environment (E)
Current/future envt & partner’s knowledge/skills, etc.,
Stakeholders (S)
S’s perspectives, attitudes towards problem
Intervention (I)
Steps to change persons, envts.
interaction, events, procedures
Comparison/Control (C)
Compare bet. Interventions or intervention & no intervention
Outcome(s) (O)
Desired outcomes

29. An example (Schlosser, Koul & Costello,2007)
Person/problem
Envt.
Stakeholders
Intervention
Comparison
Outcomes
In a 7 year-old boy with profound ID who exhibits self-injurious behavr.
Who is currently in a self-contained classroom
And whose teacher and aides suspects that his behaviour is communication based
Is it sufficient to rely on informant-based assessment methods
Or is it necessary to also conduct descriptive and experimental assessments
In order to identify the communicative functions that maintain his problem behavr. In a valid and reliable manner/

30. Ask an clinically/service relevant answerable question using PESICO
Group Work Activity 2
Ask an clinically/service relevant answerable question using PESICO

31. Step 2: Search for the evidence
To start, use the PICO/PESICO question components to identify the search terms

32. Search for the best evidence
Where to start searching depends on a number of factors:
Available time
Available databases
Subject matter and domain of the question
Currency and level of evidence required

33. Where do I search? Finding the evidence
Courses, proceedings, books,
Journals
(Two million journal articles are published annually in some 20,000 ‘biomedical’ journals)
Secondary research – meta-analysis, systematic reviews
Primary research – individual research studies
Grey literature e.g. unpublished research, theses
Indexes and databases
General eg CINAHL, Medline, PubMed, ERIC
Specialist e.g. Cochrane Library, DARE, PEDro

34. Where do I search? Finding the evidence
Hand searches
Table of contents
Ancestry search- use reference list and identify other studies
Forward citation search-who has referred to a particular article?
Finding evidence on the Internet
General search engines, e.g., Google
Specialised Search engines, Google Scholar

35. Types of Databases Bibliographic/General eg Medline PubMed
Specialist Databases
ERIC
CINAHL
PsyInfo

36. Databases – Full Text/Specialised
DARE- Database of Abstracts of Reviews of Effects (UK)
Cochrane- Cochrane Database of SR (Worldwide)
Expanded Academic ASAP
Science Direct
SCOPUS

37. Strategies for searching databases
Plan the research, efficiency
Create a search plan
Select and access the right databases
Develop a search statement
Limit, refine and evaluate
Locate the source publication

38. Strategies for Searching
1) look for pre-filtered evidence (e.g., EBM reviews, Systematic Reviews, Practice guidelines)
2) look for reviews before individual studies
3) look for peer-reviewed before non-peer reviewed
(Schlosser, Wendt, Angermeier & Shetty, 2005)

39. Create a Search Statement
Search commands – Boolean operator/connectors (or, and, not)
example: labour not pregnancy
Truncation – symbols used to substitute for characters at the end of a word e.g Ovid uses “$”
example: child$ will give children, childlike
Wildcards – symbols used to substitute for a letter within a word e.g Ovid uses #
example: wom#n will give woman and women
Check Help Screen for each database

40. Keyword Searching
Keywords – important words that represent a topic. Have no control over how a word is used in the document
The use of quotation marks is useful for example “intellectual disability”
Fields – eg author, title, abstract, journal
Limits – by date, by language, to full text, to abstracts, Systematic reviews

41. Hierarchy of Evidence http://gollum. lib. uic. edu/applied_health/
Hierarchy of Evidence University of Illinois at Chicago

42. b) Quasi-experimental group designs 2a. One well-designed non RCT,
Connective Solutions
10/10/2013
Proposed hierarchy of evidence to inform intervention development & selection: Participants with disabilities (Schlosser & Raghavendra, 2004)
Meta-analysis of
a) RCTs*, b)SSED,
b) Quasi-experimental group designs
2a. One well-designed non RCT,
2b. 1 SSED-1 intervention,
2c. 1 SSED-multiple interventions……..
3. Quantitative reviews that are non-meta-analytic
4. Narrative reviews
5. Pre-experimental group designs & Single case studies
6. Respectable Opinion
EACD, Raghavendra et al., 2013

43. Levels of Evidence
Based on the idea that different grades of evidence (study designs) vary in their ability to predict the effectiveness of the health practices
Reducing biases-Sample, Measurement/detection, Intervention/Performance
Higher grades of evidence are more likely to reliably predict outcomes than lower grades
Is a system for making sure that you are aware of the strengths and weaknesses of different study types.
Several Evidence Grading scales eg: Sackett’s Hierachy of Evidence, NHMRC, Cochrane

44. What are Systematic Reviews?
EBP Workshop, Northcott, Sydney
2/11/2009
What are Systematic Reviews?
A synthesis of original research
Pre-filtered evidence
A SR aims to synthesize the results of multiple original studies by using strategies to reduce bias
(Cook et al., 1997: Schlosser, 2003, cited in Schlosser et al., 2005)

45. Systematic Review (Adapted from Cochrane Database of Systematic reviews – & Centre for Reviews & Dissemination-
Transparent process to facilitate replication
Pre-defined, explicit methodology is used,
strict protocol to inlcude as much relevant research
original studies apparised and synthesised in a valid way
Minimise risk of bias

46. Systematic Review
Meta analysis is a mathematical synthesis of two or more primary studies that addressed the same hypothesis in the same way.
(Greenhalgh, 1997, BMJ, 315: )

47. Where to find systematic reviews
N-CEP's Compendium of Guidelines and Systematic Reviews (ASHA)
Cochrane Collaboration
Campbell Collaboration
What Works Clearinghouse (US Department of Education)
Psychological Database for Brain Impairment Treatment Efficacy
National Electronic Library for Health (National Health Service of the UK)
Evidence-based Communication Assessment and Intervention (EBCAI) Journal
Speech Byte

48. Step 3:Critically appraising the evidence
What is the evidence telling me?
Validity (truth) and usefulness (clinical relevance)

49. What is Critical Appraisal?
Appraisal is a technique which offers a discipline for increasing the effectiveness of your reading, by enabling you to quickly exclude papers that are too poor a quality to inform practice, and to systematically evaluate those that pass muster to extract their salient points”
Adapted from Miser WF (1999). Critical appraisal of literature, J. of American Board of Family practice, 12, Taken from

50. Are the findings
applicable in my
Setting?
Is the quality of the
study good enough to
use the results?
What do the results
mean for my clients?

51. Difference between reading for content vs
Difference between reading for content vs. reading for critical appraisal
Abstract
Introduction (background, literature review), aims of the study
Methodology
Results
Discussion
Abstract
Introduction (background, literature review), aims of the study
Methodology
Results
Discussion

52. Type of Study
The next step is to work out what study design will best answer your question
Levels of Evidence – reflect the methodological rigour of the study

53. Type of Question
Different types of questions are best answered by different types of studies
Your question may be:
- Intervention or therapy
- Diagnosis/screening
- Prognosis
- Aetiology or risk factors

54. Questions -> Research Designs
Therapy/intervention effectiveness…….
Test an association between…..…
Descriptive info. about relationship in one participant
Explore what factors influenced outcomes at one point in time
Describe experiences……
Experimental
Observational-Cohort/case-control
Case Study
Cross-sectional
Qualitative

55. What do you need to look for in studies?
Why was the study done?
What type of study design was used?
What are the study characteristics (PICO/PESICO)?
RELIABILITY- Test-retest, intra-rater & Inter-rater
VALIDITY (Internal validity - What biases exist?)
Participant selection, comparable groups at baseline, blinding, follow-up, drop-outs,outcomes, procedural reliability/treatment integrity)?
What are the results (size and precision of the effect)?
External validity -Are the results relevant in my clinical situation?
Social Validity

56. Critical Appraisal Tools Systematic Reviews
EVIDAAC Systematic Review Scale
(Schlosser, R. W., Raghavendra, P., & Sigafoos, J., Eysenbach, G., Blackstone, S., & Dowden, P. (2008)
Protocol
Source selection bias
Trial selection, criteria for pooling
Study quality
Data extraction
Statistical analysis
Clinical Impact

57. Appraisal of Systematic Review Paper
Group Work Activity 3
Barriers and facilitators to the use of high-technology augmentative and alternative communication devices: a systematic review and qualitative synthesis
Susan Baxter, Pam Enderby, Philippa Evans and Simon Judge,
INT J LANG COMMUN DISORD, MARCH–APRIL 2012,
VOL. 47, NO. 2, 115–129

58. Critical Appraisal Tools Randomised Control Trials (RCTs &Non-RCTs)
PEDro – P Scale- (Moseley, 1999; Maher et al., 2003)
Physiotherapy Evidence Database
To rate RCTs and Non-RCTs, not for SR, case-series, SSED
11 item scale, score 1 or 0
(based on info. found in the paper)
1st criterion - external validity
internal validity
Max.10, Min 0 (RCT=10, Non-RCT=8)
Rated for methodological quality- sources of bias
A high rating does not reflect relevance to practice

59. Critical Appraisal Tools
McMaster Forms- Developed by Law et al., 1998, Letts et al.,
Quantitative Review Form:
Was the sample described in detail?
Were the outcome measures reliable?
Was intervention described in detail?
Were the analysis methods appropriate?
Qualitative Review Form: (ver 2.0, Letts et al., 2007)
Was sampling done until redundancy in data was reached?
Was the process of transforming data into themes described adequately?
Was member checking used to verify findings?

60. Appraisal of a Qualitative Study
Group Work Activity 4
A Qualitative Analysis of Interactions of Children who use Augmentative and Alternative Communication
ANETT SUNDQVIST* and JERKER ROONNBERG
Augmentative and Alternative Communication, December 2010 VOL. 26 (4), pp. 255–266

61. References www.york.ac.uk - DARE
Auperin, A., Pignon, J.-P., & Poynard, T. (1997). Review article: critical review of meta-analyses of randomized clinical trials in hepatogastroenterology. Aliment Pharmacological Therapy, 11, 215
Maher, CG., Sherrington, C., Herbert, RD., Moseley, A., & Elkins, M. (2003). Reliability of the PEDro scale for rating methodological quality of randomised controlled trials. Physical Therapy, 83,
Moseley, AM., Maher, C., Herbert, RD., Sherrington, C. (1999). Reliability of a scale for measuring the methodological quality of clinical trials. Proceedings of the VIIth Cochrane Colloquium, Rome, Italy: Cochrane Centre, p.39.
Richardson, W., Wilson, M., Nishikawa, J., & Hayward, R. (1995). The well-built question: A key to evidence-based decisions, ACP Journal Club, 123, A12-A13.
Schlosser, R. W., & Raghavendra, P. (2004). Evidence-based practice in augmentative and alternative communication. Augmentative and Alternative Communication, 20(1),
Schlosser, R., Wendt, O., Angermeir,K., & Shetty, M. (2005). Searching for evidence in augmentative and alternative communication: Navigating a scattered literature, Augmentative & Alterntaive Communication, 21,
Schlosser, R. & O’Neil-Pirozzi, T. (2006). Problem formulation in EBP and systematic reviews. Contemporary issues in communication science and disorders, 33,5-10.
Schlosser, R., Koul, R., & Costello, J. (2007). Asking well-built questions for evidence-based practice in augmentative and alternative communication. Journal of Communication Disorders, 40 (3),
- Cochrane Collaboration
- DARE