[Dysphagia] The "crico-pharyngeal diet" that prompted evidence questions?

[Paula.Leslie at newcastle.ac.uk (Paula leslie)]

"And where are the Phase II and Phase III trials showing that our swallowing 
therapies work?"

"For instance, it would be good to provide research-based evidence that 
VitalStim therapy is not efficacious."


These two comments are very significant to me.  Because of the lack of good 
research methods training for practicing clinicians and the lack of robust 
evidence, we set up an MSc to tackle this in dysphagia and dysphonia.  To 
develop such skills in specialist clinicians (SLT/Ps, ENTs etc) already 
working in these fields, in an interdisciplinary format.  And let's face it 
although we all learnt this stuff at college, it's either taught badly or it 
happened a long time ago (or both) and it's only now after working in the 
field that we have the knowledge to form the questions.  It is not good enough 
to say "well there's no proof for most of what we do - so why do we need proof 
for something new?"  Nor is it acceptable for us to say "ah well I will use 
this until someone proves it doesn't work."  Would you take a medicine that 
had been launched on the public that way?

As psmith & Linda A. Zanchi pointed out the lack of evidence to support our 
work in swallowing is a very serious issue.  We do need to be creative and 
develop new approaches - creativity should not be stifled.

We can't help the fact that a lot of existing intervention is not evidence 
based but we can start to examine it, and prove where it does work, where it 
needs improving, and where it needs ditching.  We need good studies to do this 
- bad studies will harm the potential of the intervention and the professions 
involved.  The wealth of clinical experience that people have with existing 
interventions should be harnessed and used to design APPROPRIATE research 
questions.  Evidence based medicine is founded upon three things: the best 
evidence available + clinician experience + patient preference.

http://www.cebm.net/ebm_is_isnt.asp

Evidence-Based Medicine: What it is and what it isn't.
David L Sackett, William MC Rosenberg, JA Muir Gray, R Brian Haynes, W Scott 
Richardson

"Evidence-based medicine is 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 expertise with the best available external clinical evidence from 
systematic research. By individual clinical expertise we mean the proficiency 
and judgment that individual clinicians acquire through clinical experience 
and clinical practice. Increased expertise is reflected in many ways, but 
especially in more effective and efficient diagnosis and in the more 
thoughtful identification and compassionate use of individual patients' 
predicaments, rights, and preferences in making clinical decisions about their 
care. By best available external clinical evidence we mean clinically relevant 
research, often from the basic sciences of medicine, but especially from 
patient centred clinical research into the accuracy and precision of 
diagnostic tests (including the clinical examination), the power of prognostic 
markers, and the efficacy and safety of therapeutic, rehabilitative, and 
preventive regimens. External clinical evidence both invalidates previously 
accepted diagnostic tests and treatments and replaces them with new ones that 
are more powerful, more accurate, more efficacious, and safer."

We are in this job because we care about our patients/clients and sometimes 
desperation to help will push us to try absolutely anything.  It may be that 
most of what we do will one day be proven to be worthless and we will have to 
accept that.  But it is far better that our professions are involved in 
designing and implementing APPROPRIATE trials to establish the evidence base 
than we wait until some other Health Professional, Scientist or (?worst of 
all) Financier does this.  Would they know the right question to ask and 
understand the issues involved like we would?  Dysphagia is a disorder 
spanning many professions, and intervention and research must be implemented 
in the same way.

If we harnessed the half energy (and ?$s) that goes into teaching and 
defending unsupported interventions we would have a sizable resource to put 
into the creation of an evidence base.

And I'll just step down of my Monday morning soapbox, sorry for such a long 
rant!  Hope your clinics are quiet!

Paula

Paula Leslie
Degree Programme Director

Note: UK Swallow Research Group Inaugural Meeting 2nd December, London
Please contact me for details!!!!

Surgical and Reproductive Sciences
Faculty of Medical Sciences
University of Newcastle
Newcastle upon Tyne
NE2 4HH
UK
+44 (0) 191 222 6279(T)/8988(F)
http://www.ncl.ac.uk/sars/postgrad/MSc.htm