6ContextHistoricalVoice therapy using a series of “facilitating techniques” (e.g., Boone)Distinctive advance at time of introduction; first systematic assembly of wide range of voice therapy techniques, rationale, and case examplesinternet-d.com
7Context Concern Voice therapy approaches based on trial and error Approaches lacked cohesive theoretical frameworkApproaches lacked empirical data (difficult to research due to idiosyncratic nature of combining “techniques” )bananabelt.org
8Next generation “Packaged” therapies Lee Silverman Voice Treatment (Ramig)Vocal Function Exercises (Stemple)Laryngeal massage (Roy)Lessac-Madsen Resonant Voice Therapy (Verdolini)Accent Method (Smith et al.)amassblog.com
9Next generation Advantages Cohesive frameworks Systematic programs allowing for (a) formal clinician training; (b) scrutiny by evidence-based medicineshebamuturi.wordpress.com
10Next generation Concerns Nearly evangelical enthusiasm for some programscnimf.org
11Next generationConcernsTendency towards “cookbook” orientation
12Next generation Concerns Qualifier Questions about “evidence-based medicine” (warning: next slides, minor tirade)QualifierEBM is a generally a good thing, overallI make a living doing EBMI know how to do EBMI simply voice some cautionary concerns meant to “temporize”broadstreetbuzz.com
13Stated differently New type of authority Many clinicians seemed as robotic about the new master (EBM) as we did about the old one (“expert opinion”).We need to evaluate the concept and practice of “EBM” judiciously.
14Evidence-based medicine “The dark side”(Term coined by Eva van Leer)alum.wpi.edu
15What’s the problem??? The issue seems innocent enough. Pipicasaweb.google.comEBM defined as “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical experience with the best available external clinical evidence from systematic research.” Sackett et al. BMJ. 1996;312:71-72.
18EBM P1(RCT) RCTs and RCT meta-analysis as “best evidence” (why???) Reveal average results for average patient; what about your patient???Success of randomization depends on the law of (really) large numbers (think insurance companies), which we never have in SLP trialseducation.com
19EBM P1(RCT) I.e., there are concerns about deductive reasoning Deductive reasoning goes from population to individualWorks well for actuarial purposes (“average” result; relevant for insurance companies) but not necessarily so well for your individual patientsCasuistic reasoning is at least as defensible for clinical practiceReasoning by analogy (e.g., similar cases)Can be rigorousTonelli, 1998; see also Samarkos, 2006
20EBM P2 (Role of “evidence”) “Evidence” crowds out experience, values, and resources in the modelProponents of EBM remind us that experience, values, and resources are in the model.
21EBM P2 (Role of “evidence”) Then why is it still called “evidence-based medicine???”
22EBM P3 (Philosophy of science) Basic assumption in science is the future will act like the past (e.g., David Hume; John Cobb)Fundamental fallacyFuture conditions are never identical to past conditionsEven if conditions were identical, stochasticity (randomness) determines different results
23EBM P3 (Philosophy of science) So are there basic philosophical cautions about what evidence from the past can tell us about our patient in the future?Hahammertap.com
24EBM P4 (Reality of nature) ComplexityNon-linearityVariabilityStochasticity (random element)E.g. Li et al., 2009;Moreover, human health is much more complex than typically implied by linear models in most EBM:y = mx + b (linear)
25EBM P4 (Reality of nature) faculty.uca.edum arkettechnologies.com
26EBM P5 (Epistemology) Epistemology How do we come to “know” things? Only standing “outside the problem” as with “evidence,” or also standing “inside the problem” (explanation follows)?
27EBM P6 (Evidence itself!) There is no evidence that evidence-based medicine improves clinical outcomes!naturalhealthcarereviews.com
28Possible solutionsEvidence: Expand the scope of type of “evidence” we use, beyond RCTsBeyond evidence: ReclaimFirst principlesIntuition and creativitysimple.wikipedia.org
29Possible solutions: Expanding scope of “evidence” SS evidence: Casuistic reasoning (reasoning by analogy, including analogy with other patients of yours, i.e., “in my hands” evidence) (Tonelli, 1998; see also Samarkos, 2006)totallylookslike.icanhascheezburger.com; I’m sparing you the George W. Bush look-alike
30Possible solutions: Beyond “evidence” The principle of “first principles”Many first principles don’t need clinical “evidence” about their clinical utility, and can be used flexiblyE.g., parachute studygreenstandardstrust.wordpress.commoonfrye.ning.com
31Parachute study Int J Prosthodont. 2006 Mar-Apr;19(2):126-8. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.Smith GC, Pell JP.SourceDepartment of Obstetrics and Gynaecology, Cambridge University, United Kingdom.AbstractOBJECTIVES:To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Design Systematic review of randomised controlled trials.DATA SOURCES:Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists.STUDY SELECTION:Studies showing the effects of using a parachute during free fall.MAIN OUTCOME MEASURE:Death or major trauma, defined as an injury severity score > 15.RESULTS:We were unable to identify any randomised controlled trials of parachute intervention.CONCLUSIONS:As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.
32Beyond “evidence”First principles: To a great extent, this course is about first principles we can use to flexibly create individualized voice therapy (with examples in packaged “templates”).
33Possible solutions: The case for intuition and creativity Reclaiming intuition and creativityFirst step is being fully present (to capture cues we miss when we’re “in our heads”)inspiration-for-singles.com
34Possible solutions: The case for intuition and creativity Reclaiming intuition and creativityPotential reliance on mirror neurons to solve clinical challenges creatively in the moment (e.g., Rizzolatti & Craighero, 2004) slog.thestranger.comPotential reliance on nonconscious “data base” we have accumulated clinically, allowing for “intuitive pattern detection (e.g., master chess players; Kahneman v. Klein, 2009)
35Possible solutions: The case for intuition and creativity Reclaiming intuition and creativityTo a great extent, this course is also about reclaiming intuition and creativity as partially valid foundations for principled individualized voice therapy (examples of therapies shown in “packaged” LMRVT and CBCFT, but we will go beyond).seotipss.com
36Purposes of courseProvide overview of critical “building blocks” (first principles) for voice txExamine existing packaged therapies for their relation to identified first principles.Train two tx “packages” that are examples of how the building blocks may be assembled (LMRVT and CBCFT), and associated outcome data.Demonstrate how intuition and creativity can be used in a principled, systematic way “in the moment” to create individualized voice therapy (IPTIM).dandelionsummers.com
37Real agendaFor you to acquire fundamental building blocks in how to construct personalized voice therapy.For you to reclaim for yourself the dignity of intuition and creativity in the therapy process.encore.sla.org
42Aside Vocal abuse/misuse: We’ve gotten rid of these terms, right? CircularPoorly definedIndistinctPotentially negative for therapy outcome (by way of self-efficacy and compliance; Bandura, 1977)Verdolini, 1999
43Basic building blocksThree parameters are necessary and sufficient to address in voice therapyPhysiology (biomechanics, biology): “What?”Learning: “How?”Compliance: “If?”science-art.com
44General proposal Knowledge regarding the three parameters Is distinct Is desirable to optimize likelihood of therapy successen.wikipedia.org
45Structure of seminar Basic science (“building blocks”) Biomechanics/biologyMotor learningPatient compliance“Evidence:” RCTs ApplicationsStep by step details and practice with LMRVT and CBCFTDemonstrations and practiceIntro to “IPTIM” “individualized principled therapy in the moment” (aka “unscared therapy;” intuition and creativity)