Evidence-Based Practice for Cognitive-Communication Disorders after Traumatic Brain Injury

As clinicians, we sincerely believe that our intervention improves the lives of those we serve. In the case of neurogenic communication disorders, however, this belief is not always supported by data. The disability rights movement in the 1980s led us to consider client outcomes beyond clinical settings, and we had little measurable evidence that our intervention made a meaningful difference in these contexts. Reimbursement limitations further forced us to scrutinize our practice for evidence of both efficacy (a significant benefit demonstrated in a clinical trial) and effectiveness (benefit to an individual in clinical practice). At the same time, there was a movement toward evidence-based practice in medicine, led in part by the Evidence-Based Medicine Working Group at McMaster University in Ontario, Canada. Thus, we joined a community of health care practitioners engaged in the process of creating evidence-based guidelines for intervention.

The Academy of Neurologic Communication Disorders and Sciences (ANCDS) has been working since 1997 to develop evidence-based practice guidelines specifically for acquired neurogenic communication disorders. LeeAnn Golper summarized the goals of the project in the initial publication of the guidelines group, stating that “The goal of this project is to improve the quality of services of individuals with neurologic communication disorders by assisting clinicians in decision-making about the management of specific populations through ‘guidelines’ based on research evidence”.[1] Additional support for the ANCDS evidence-based practice project has come from the American Speech-Language-Hearing Association (ASHA), Division 2, Neurophysiology and Neurogenic Speech and Language Disorders, and the Department of Veterans Affairs.

The ANCDS guidelines project has proved to be a Herculean task. It has required the efforts of several teams of individuals, including students who have participated in collecting and summarizing data as well as colleagues who have provided peer reviews of numerous documents. Evidence reviews are published or under way in the areas of dysarthria, dementia, aphasia, childhood apraxia of speech, and, as in the clinical focus articles included in this issue, cognitive-communication disorders associated with traumatic brain injury (TBI) . There are two excellent sources of updated information about the guidelines project: the ANCDS Web site (www.ancds.org) and the regular ANCDS column included in the ASHA Division 2 quarterly Perspectives publication. Readers are referred to these for more comprehensive information about the project and its products.

The cognitive-communication disorders writing group chose to present results in several formats, in accordance with deficits typically encountered by persons with TBI.[2] Thus, we took a modular approach to reviewing the literature and current practice for the following areas: intervention for attention disorders,[3] standardized assessment,[4] nonstandardized assessment, the use of external memory aids, intervention for deficits of executive function and metacognition, intervention for social and behavioral disorders, and intervention that includes direct instruction. To reach the widest readership, several formats have been used, including technical reports, posted on the ANCDS Web site; comprehensive guidelines papers, some of which have been published in the Journal of Medical Speech-Language Pathology with others forthcoming; and a series of “clinical focus” articles, several of which are presented in this special issue.

In the first article, Turkstra, Coelho, and Ylvisaker review standardized, norm-referenced tests that are currently used by clinicians to evaluate language and cognitive-communication disorders. Coelho, Ylvisaker, and Turkstra then discuss the evidence related to the use of nonstandardized approaches to assessment, particularly for outcomes at the level of communication activities and participation as a preview to the technical report and recommendations

Kennedy and Coelho focused their review on the evidence for the use of self-regulation in intervention for memory and problem solving, which is part of a broader review of intervention for disorders of executive function and metacognition. In the next article, Ylvisaker, Turkstra, and Coelho discuss intervention for social and behavioral problems affecting communication. The final article, by Sohlberg, Ehlhardt, and Kennedy, discusses the use of direct instruction as a strategy for changing behavior.

Anyone who has ever tried to evaluate the “evidence” and make clinical recommendations realizes immediately that it is a dynamic process that can change from year to year. One year there may be limited evidence that only suggests that an intervention is efficacious, but in subsequent years the evidence may be mounting. The need for more evidence is obvious. Regardless of what the evidence suggests, each clinician must ultimately make decisions about the best intervention for each client, and to do that, clinicians must balance the evidence with the client's own goals, needs, and values. As the Evidence-Based Medicine Working Group[5] noted, there is no substitute for clinical judgment in choosing the most appropriate assessment and intervention for an individual client.

REFERENCES

• 1 Golper L C, Wertz R T, Frattali C M et al.. Evidence-based practice guidelines for the management of communication disorders in neurologically-impaired individuals: project introduction. In: http://www.ancds.duq.edu/guidelines.html 2001
• 2 Kennedy M, Avery J, Coelho C et al.. Evidence-based practice guidelines for cognitive-communication disorders after traumatic brain injury: initial report of the Academy of Neurologic Communication Disorders and Sciences Writing Committee for practice guidelines in cognitive-communication disorders after traumatic brain injury.  J Med Speech Lang Pathol. 2002;  10 ix-xiii
• 3 Sohlberg M M, Avery J, Kennedy M et al.. Practice guidelines for attention training.  J Med Speech Lang Pathol. 2003;  , (In press)
• 4 Turkstra L, Coelho C, Ylvisaker M et al.. Practice guidelines for standardized assessment for persons with traumatic brain injury.  J Med Speech Lang Pathol. 2005;  13 ix-xxviii
• 5 Guyatt G H, Haynes R B, Jaeschke R Z for the Evidence Based Medicine Working Group et al.. Users' guide to the medical literature.  JAMA. 2000;  284 1290-1296