E vidence-Based Pr ac tice in Speech-

Language Pathology: Scaling Up

Laura M. Justice
356 Arps Hall, 1945 N High Street, The Ohio State University, Columbus OH 43210

Abstract

Evidence-based practice is a process to which clinical professionals adhere when making decisions concern-
ing the assessment or treatment of a given condition. Within the field of speech-language pathology, it is
increasingly advocated as best practice. As our profession seeks to transform itself from one that is primar-
ily craft-based to one that relies on evidence-based processes, it must develop and implement a series of
structures that will foster this transformation. This article describes three specific structures that are increas-
ingly available within the field of speech-language pathology in the United States to guide transformation of
the profession: systematic reviews and meta-analyses, treatment studies, and clearinghouses. Without these
structural supports, it is unlikely that evidence-based practice can be scaled up in a way that has positive
impacts on practice.

Keywords: evidence-based practice, systematic review, meta-analysis

E
vidence-based practice is a process to which sequence the nature and impact of the decisions to
clinical professionals adhere when making be made, the process of evidence-based practice is
decisions concerning the assessment or treat- largely identical regardless of whether one is select-
ment of a given condition. This process involves care- ing a treatment regiment for high blood pressure, for
ful consideration and integration of various types of clinical depression, for stuttering, or for reading dis-
evidence so that the most effective solution can be ability. As members of the speech-language pathol-
identified; these types of evidence include, minimally: ogy community, it can be particularly insightful to
(1) clinical expertise, (2) patient values and perspec- examine the structures being put into place in other
tives, and (3) best available scientific evidence (Sack- professions – medicine and education, for instance
ett, Rosenberg, Gray, Haynes, & Richardson, 1996; – as we transform our profession towards one that is
Sackett, Straus, Richardson, Rosenberg, & Haynes, evidence-based.
2000). Evidence-based practice is recommended If we look to the larger literature on evidence-
for use not only by speech-language pathologists, based practice, it is evident that all professions seek-
but also those involved with clinical decision-mak- ing transformation from craft-based to evidence-
ing in medicine (called evidence-based medicine; based clinical decision-making models are in the
Evidence-Based Medicine Working Group, 1992), process of designing and implementing complex
nursing (Porter-O’Grady, 2007), psychology (Spring,
2007), physical therapy (Cibulka & Aslin, 2001), and Author Contact: Laura M. Justice, 356 Arps Hall, 1945 N High
special education (Cook & Shirmer, 2006), among Street, The Ohio State University, Columbus OH 43210. Email:
others. Regardless of one’s discipline and, by con- [email protected]

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 E vidence-Based Prac tice in Speech-Language Pathology: Scaling Up

types of structures to not only ease this transforma- ments developed by teams of experts to guide prac-
tion but to make it even possible in the first place; titioners in how to make decisions regarding specific
some professions are much further along than oth- circumstance (Field & Lohr, 1990). Although they
ers. By structures, I am referring to tangible items and may be developed through a systematic process,
tools that must be developed to allow a profession practice guidelines do not typically involve a com-
to become more embedded in evidence. These struc- prehensive review of the literature on a specific topic
tures include, for instance, providing guidelines to nor a critical analysis of available statistical data; they
clinicians as to how to formulate well-built clinical may, as a result, offer flawed interpretations of the lit-
questions (Schlosser, Koul, & Costello, 2007), de- erature that represent the biases of those experts who
veloping consensus statements regarding how much are involved in generating the guidelines (Woolf,
and what type of evidence is needed for a treatment Grol, Hutchinson, Eccles, & Grimshaw, 1999). In
to be “empirically validated” (Gersten, Fuchs, Comp- the field of medicine, experts express concerns that
ton, Coyne, Greenwood, & Innocenti, 2005), and ar- clinicians’ use of practice guidelines can result in use
ticulating the sequenced steps that clinicians must of “ineffective, harmful, or wasteful interventions”
follow so that they might conduct their own critical (Woolf et al., p. 329).
appraisals of the scientific literature (e.g., Fey & Jus- As medicine and other professions, like speech-
tice, 2006; Justice & Snell, 2007). Within the field language pathology, seek to take evidence-based
of speech-language pathology, these and many other practice to scale, we see increased utilization of alter-
structures necessary for the successful transforma- natives to practice guidelines – the systematic review
tion of a profession to one that is evidence-based are and the meta-analysis - that offer a more systematic
in the process of being developed and have not, to and potentially less biased approach towards synthe-
any large extent, yet been taken to scale. Nonetheless, sizing available research literature for the clinician.
all signs point to the scaling up of evidence-based A systematic review is a scientific investigation of
practice in the near future given that many relevant the available literature on a given topic. The review is
structures are being put into place. systematic because the individual(s) completing the
Evidence-Based Practice in the United States: review adheres to a rigorous and preplanned process
Structures Promoting Scalability for identifying potential research articles for inclu-
In this article, I discuss three specific structures sion, appraising these articles to identify key find-
that are increasingly available within the field of ings, and for synthesizing findings across the iden-
speech-language pathology in the United States: sys- tified body of work. A qualitative systematic review
tematic reviews and meta-analyses, treatment stud- does not involve statistical analysis of the research
ies, and clearinghouses. These three structures are, in findings aggregated across studies, whereas a quanti-
my opinion, necessary tools for clinicians to engage tative systematic review – also called a meta-analysis
in evidence-based practice and for a field to success- – is a type of quantitative research design that in-
fully transform itself to one that is evidence-based; volves statistically examining the aggregated results
their increasing availability provide evidence of the of a systematic review to determine the average level
scaling up of evidence-based practice. of effects attributable to a specific independent vari-
Systematic Reviews and Meta-analyses able. The independent variable may involve treat-
Historically, speech-language pathologists in the ment (e.g., average effects attributable to receiving
United States have used practice guidelines (also specific types of treatment), measurement (e.g., aver-
called clinical guidelines) to help them answer press- age diagnostic accuracy of specific types of tests), and
ing clinical questions. Practice guidelines are state- general aspects of development or disability (e.g., av-

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Laura M. Justice

erage concurrent or predictive association between not involve this type of analysis and therefore such
two aspects of development, such as reading skill and interpretations are not possible. A unique strength
intelligence or language ability and history of otitis of the meta-analysis is in the statistical combining of
media). Typically, a meta-analysis reports average ef- data across multiple studies and the resulting effect
fect sizes associated with a specific treatment or meas- size estimates.
ure that is created by combining and then averag- For professions that are seeking transformation
ing data provided in each study in a set. An effect towards being evidence-based, an important recent
size is, essentially, the strength of an effect as repre- event is the shift towards generation of evidence-
sented in standard deviation units, typically reported based systematic reviews and evidence-based clini-
using Cohen’s d for estimating differences between cal guidelines as replacements for traditional practice
groups (e.g., for analyses of variance), or percentage guidelines. These are similar to traditional prac-
of variance accounted for, reported using r2 for cor- tice guidelines in that they attempt to offer clini-
relational data. There are guidelines available in the cians useable knowledge regarding a particular clini-
literature, the most commonly used being those of cal problem, but they are generated through a much
Cohen (1988), that discuss how to interpret effect more systematic process than occurs with practice
size estimates so that one knows if an average ef- guidelines. The American Speech-Language-Hear-
fect reported in a meta-analysis is small, medium, or ing Association, in response to recommendations of
large in size. Meta-analysis is most suitably applied the Joint Coordinating Committee on Evidence-
when there are a reasonable number of studies avail- Based Practice (American Speech-Language-Hear-
able on a given topic, as too few studies can bias the ing Association, 2005), has shifted from generat-
results of a meta-analysis in both positive and nega- ing practice guidelines to evidence-based systematic
tive directions. reviews and is in the process of accepting nomina-
To successfully engage in evidence-based practice, tions for topics to address. The first evidence-based
clinicians must have access to systematically con- systematic review has undergone public comments
ducted, valid systematic reviews of the accumulated and will be published in the near future; it exam-
literature to date. Qualitative systematic reviews can ines the accumulated literature on the efficacy of
be particularly helpful for clinicians to understand constraint-induced language intervention for use in
what is known about a particular area of inquiry. For aphasia rehabilitation. The Academy of Neurologic
instance, Coelho, DeRuyter, and Stein (1996) pro- Communication Disorders and Sciences (2001) also
vided a useful synthesis of efficacious treatment ap- has embarked on developing evidence-based practice
proaches for cognitive-communication impairments guidelines relevant to management of communica-
of adults secondary to traumatic brain injury. This ar- tion disorders in neurologically impaired individu-
ticle summarized the results of various approaches to als, to include traumatic brain injury, dementia, and
treating this condition, although it did not statisti- aphasia, among others.
cally compare the average effects associated with any In addition to these initiatives at the national level,
one treatment approach (e.g., mnemonic training) it is also relevant to note that several meta-analyses
with that of other treatment approaches (visual im- have been produced in recent years that greatly bene-
agery, executive strategy training), nor did it provide fit clinician’s engagement in evidence-based practice.
a summary of the average strength of effects associ- The results of meta-analyses permit the speech-lan-
ated with a specific training. It may be that one ap- guage pathologist to make more informed decisions
proach has very strong effects compared to other ap- about the benefits that can reasonably be expected
proaches, but the qualitative systematic review does from a particular type of treatment. In the area of

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 E vidence-Based Prac tice in Speech-Language Pathology: Scaling Up

treatment, meta-analysis have studied general treat-

Table 1. ment effects for aphasia (Robey, 1998), child language
Examples of meta-analyses on clinically relevant disorders (Law, Garrett, & Nye, 2004), communica-
topics in speech-language pathology tion problems associated with autism (Goldstein,
Topic Citation
2002), fluency disorders (Andrews, Guitar, & Howie,
1980), and attention problems associated with trau-
Treatment of Law, J., Garrett, Z., & Nye, C.
child language (2005). The efficacy of treatment for
matic brain injury (Park & Ingles, 2001), to name
disorders children with developmental speech several. More specific aspects of treatment have also
and language delay/disorder: A
meta-analysis. Journal of Speech,
been explored, such as the average effects associ-
Language, and Hearing Research, ated with particular treatment approaches (e.g., in-
47, 924-943. tratympanic gentamicin for Menière’s Disease; Co-
Impact of Cohen, S. M., Dupont, W. D., & hen-Kerem et al., 2004; behavioral treatments for
voice Courey, M. S. (2006). Quality of life stuttering; Herder, Howard, Nye, & Vanryckeghem,
disorders on impact of non-neoplastic voice
quality of life disorders: A meta-analysis. Annals 2006) or treatment contexts (e.g., pull-out for inclu-
of Otorhinolaryngology, 115, 128- sive models of language intervention; McGinty &
134.
Justice, 2006). Table 1 lists several meta-analyses that
Treatment of Whurr, R., Lorch, M., & Nye, C. are likely to be of interest to clinicians.
aphasia (1992). A meta-analysis of studies
carried out between 1946 and 1988 Meta-analyses are useful not only for estimating
concerned with the efficacy of the effects of specific approaches to treatment, they
speech and language therapy
treatment for aphasic patients. are also quite important for demonstrating to the
International Journal of Language field where there are serious gaps in our knowledge.
and Communication Disorders, 27,
1-18. For instance, McGinty and Justice (2006) conducted
a meta-analysis of outcomes attributable to various
Treatment of Robey, R. (1998). A meta-analysis
aphasia of clinical outcomes in the treatment
treatment contexts (e.g., classroom-based, pull-out)
of aphasia. Journal of Speech, for children with language disorders; they identi-
Language, and Hearing Research,
41, 172-187.
fied only three studies to date that have explicitly ad-
dressed this issue. As this example shows, as the field
Treatment of Boutsen, F., Cannito, M. P., Taylor,
spasmodic M., & Bender, B. (2002). Botox
of speech-language pathology scales up evidence-
dysphonia treatment in adductor spasmodic based practice within the clinical realm, speech-lan-
with Botox dysphonia. Journal of Speech, guage researchers must also ensure that the kinds of
Language, and Hearing Research,
45, 469-481. studies they are conducting produce useable knowl-
edge that contribute to timely and pressing issues
Treatment of Ruotsalainen, J. H., Sellman, J.,
functional Lehto, L., Jauhiainen, M., & within clinical practice.
dysphonia Verbeek, J. H. (2007). Interventions Treatment Studies
for treating functional dysphonia in
adults. Cochrane Database of Speech-language pathologists who engage in ev-
Systematic Reviews, 3 (# idence-based practice will turn not only to meta-
CD006373)
analyses for guidance in decision-making but also
Treatment of Hopkins, C., Yousaf, U., & to individual treatment studies. As noted earlier, a
hoarseness Pedersen, M. (2006). Acid reflux
secondary to treatment for hoarseness. Cochrane meta-analysis is really only useful when there are
acid reflux Database of Systematic Reviews, 1 enough studies in a given area that aggregation of
(#CD005054)
findings is possible. However, in many areas of prac-
tice there are far too few studies available on a given

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Laura M. Justice

topic for a meta-analysis to be useful. For instance, ers who study the efficacy and effectiveness of spe-
the clinician who works with an adolescent who stut- cific interventions and treatments using randomized
ters and wants to treat the child’s anxiety and embar- controlled trial (RCT) research designs have greatly
rassment about speaking publicly will find no meta- increased. Many of these studies are of direct rele-
analysis available on this topic (Yaruss & Pelczarski, vance to speech-language pathologists, such as stud-
2007). The clinician will then have to look towards ies of the efficacy of various language curricula for
individual treatment studies and examine these for children at-risk for academic difficulties ( Justice,
guidance on a particular approach that appears to be Mashburn, Pence, & Wiggins, 2008). The Nation-
efficacious. al Institutes of Health – and particularly the Insti-
While this seems straightforward, the field of tute that funds a great deal of research relevant to
speech-language pathology is plagued by a paucity of speech-language pathologists, the National Institute
treatment studies. One recent study of group-design on Deafness and Other Communication Disorders
treatment studies published in three flagship Amer- (NIDCD) – has recently reported its intent to pri-
ican journals in speech-language pathology (Lan- oritize funding for “patient-oriented research” over
guage, Speech, and Hearing Services in Schools; Ameri- less clinically-relevant basic research. One particu-
can Journal of Speech-Language Pathology; Journal of lar funding mechanism available through NIDCD
Speech, Language, and Hearing Research) found that prioritizes treatment research through its emphasis
only 52 such studies were published over a 10-year on funding research that “translates basic research
period – averaging about 5 studies per year ( Justice, findings into clinical tools” (NIDCD, 2007). Types
Nye, Schwarz, McGinty, & Rivera, 2008). Given that of research activities supported through this funding
these studies address a broad range of treatment foci mechanism include: (a) dosage studies, (b) interven-
of relevance to speech-language pathology (e.g., flu- tion development studies, and (c) studies of preven-
ency, voice, language, speech, literacy), it is clear that tion programs. In light of relatively stagnant levels
clinicians’ access to treatment research is inadequate of funding for social and behavioral research within
for meeting the broad range of clinical questions the United States and the increasingly competitive
they encounter in everyday practice. As noted by nature of research funding, it is likely that we will
members of the American Speech-Language-Hear- see more speech-language researchers shift their re-
ing Association, a consequence of the field’s transfor- search towards more treatment-oriented work, there-
mation to evidence-based practice is the urgent need by fostering an increase in the number of treatment
for research that addresses pressing clinical questions study publications. Indeed, members of the Ameri-
(American Speech-Language-Hearing Association, can Speech-Language-Hearing Association (2005)
2005). have specifically recommended an increase in the
Some evidence suggests that the generally limit- conduct of randomized controlled trials by research-
ed production rate of treatment research is on the ers in speech-language pathology.
brink of change, and this is largely in response to An important issue related to treatment studies
shifts in the funding streams that support empirical and their relevance to clinicians’ engagement in evi-
research in speech-language pathology. The Institute dence-based practice regards the quality and quan-
of Education Sciences, which funds the majority of tity of studies available on a given topic. The quality
educational research in the United States, has dra- of an empirical study, particularly those investigat-
matically shifted its funding priorities in the last five ing treatments, largely concerns its internal validity
years to emphasize the production of more useable and its external validity. Study methodologies that
knowledge. As a result, funds provided to research- promote internal validity (e.g., randomization of pa-

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 E vidence-Based Prac tice in Speech-Language Pathology: Scaling Up

Table 2. tients, blinding of assessors) are what allow research-

Recent treatment studies on clinically relevant topics ers to make strong causal statements regarding the
in speech-language pathology manipulated independent variable (e.g., Treatment
X) and a specific dependent variable (e.g., language
Topic Citation
comprehension). Study methodologies that promote
Treatment for Throneburg, R. N., Calvert, L. K., external validity (e.g., random selection from a pop-
child language Sturm, J. J., Paramboukas, A. A.,
disorders & Paul, P. J. (2000). A comparison ulation) are what allow researchers to make strong
of service delivery models: Effects
of curricular vocabulary skills in the
statements regarding the generalization of findings
school setting. American Journal from their sample to a larger population. Not all
of Speech-Language Pathology, 9,
10-20. studies are done well ( Justice et al., 2008) and those
that are of poor quality can lead the clinician engag-
Treatment for Tyler, A. A., Lewis, K. E., Haskill,
child A., & Tolbert, L. C. (2003). ing in evidence-based practice to make undesirable
phonological Outcomes of different speech and
disorders language goal attack strategies. treatment recommendations. The quantity of studies
Journal of Speech, Language and available on a given topic is an additional issue of rel-
Hearing Research, 46(5), 1077-
1094. evance to evidence-based practice. The clinician’s ac-
Treatment for Yoder, P. J., & Warren, S. F.
cess to one study showing a positive effect for a given
prelinguistic (2001). Relative treatment effects treatment should not be nearly so influential to his
communication of two prelinguistic communication
interventions on language or her decision-making as having access to five stud-
development in toddlers with
developmental delays vary by
ies that show consistently positive treatment effects.
maternal characteristics. Journal of Knowledge is created through the accumulation of
Speech, Language, and Hearing
Research, 44(1), 224-237. evidence and our practices should change only when
there is a preponderance of compelling high quality
Treatment of Riley, G. D., & Ingham, J. C.
stuttering (2000). Acoustic duration changes evidence.
associated with two types of
treatment for children who stutter.
An important structure that has yet to be devel-
Journal of Speech, Language and oped in the field of speech-language pathology in
Hearing Research, 43(4), 965-978.
the United States is explicit guidance regarding how
Treatment for
aphasia
Elman, R. J., & Bernstein-Ellis, E.
(1999). The efficacy of group
many treatment studies are needed for a given treat-
communication treatment in adults ment to be considered “empirically validated.” At the
with chronic aphasia. Journal of
Speech, Language and Hearing present, a speech-language pathologist may consider
Research, 42(2), 411-419. a specific treatment to be “empirically validated” or
Treatment for Chapman, S. B., Weiner, M. F., scientifically based on the basis of only a single study
dementia Rackley, A., Hynan, L. S., &
Zientz, J. (2004). Effects of of any design reporting positive effects of that treat-
cognitive-communication ment. This is problematic in a number of ways, the
stimulation for Alzheimer's disease
patients treated With Donepezil. least being that the authors of a study may readily
Journal of Speech, Language and
Hearing Research, 47(5), 1149-
argue positive treatment effects even when the study
1163. design does not permit strong causal claims or there
Treatment for Berninger, V. W., Vermeulen, K., was a fatal flaw in the design. Other fields have set
reading
difficulties
Abbott, R. D., McCutchen, D.,
Cotton, S., Cude, J., et al. (2003).
minimal standards regarding the strength of evi-
Comparison of three approaches dence needed – in terms of both quantity and quality
to supplementary reading
instruction for low-achieving of treatment studies – for a practice to be empirical-
second-grade readers. Language,
Speech, and Hearing Services in
ly validated (e.g., Lonigan, Elber, & Johnson, 1998).
Schools, 34(2), 101-116. However, the field of speech-language pathology has

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Laura M. Justice

yet to develop this important structure which, in my analyses that summarize a body of work for the busy
opinion, is absolutely necessary for clinicians to be clinician. These reviews and meta-analyses are typi-
discerning consumers of the accumulating empiri- cally prepared by experts in the field and they must
cal literature and to successfully engage in evidence- follow specific guidelines regarding how to identify
based practice. studies on a specific topic, how to analyze these, and
Clearinghouses how to report findings.
Speech-language pathologists are busy. In an era Likely the two most well known clearinghouses
of limited financial resources, clinicians are constant- are that of the Cochrane Collaboration (www.co-
ly being asked to do more for less. As a result, it is chrane.org) and the Campbell Collaboration (www.
unreasonable to expect speech-language pathologists campbellcollaboration.org). Both are international
to conduct a thorough high-quality review of the non-profit organizations that exist specifically to de-
empirical literature for every clinical issue that they velop systematic reviews of the available literature on
must address. Not only do clinicians lack the time to treatment and assessment in the field of health and
engage in such activities, but they may not have ac- medicine (Cochrane) and social and behavioral sci-
cess to the physical resources to do so (e.g., electronic ences (Campbell). Not only do these organizations
journals, databases) and they may not have the skills provide access to a large database of reviews on a
necessary to conduct what amounts to an informal range of clinically relevant topics, but numerous tools
meta-analysis of the accumulated research papers are available to support one’s developing knowledge
available on a given topic. Consequently, an absolute- of how to engage in evidence-based practice and
ly critical resource necessary for the scaling up of evi- how to conduct critical reviews of the scientific lit-
dence-based practice is the development of clearing- erature. A more recent addition is the What Works
houses that allow clinicians to study condensed and Clearinghouse (ies.ed.gov) of the United States
useable descriptions of the accumulated scientific lit- Department of Education; this clearinghouse both
erature on a specific topic. Currently, there are two commissions and disseminates systematic reviews of
types of clearinghouses that provide interpretations educationally-relevant interventions on various top-
of the empirical literature: (1) clearinghouses that ics (e.g., Phonological Awareness Training, Shared
publish systematic reviews and meta-analyses that Book Reading) but also gives “ratings of effective-
are commissioned or volunteered to address specific ness” to specific interventions that include positive
topics, and (2) clearinghouses that provide links to effects, potentially positive effects, mixed effects, no
resources on evidence-based practice, such as lists of discernable effects, and potentially negative effects;
studies on a given topic and links to practice guide- additionally, studies included in their reviews are also
lines on specific topics. Examples of this latter type graded for the quality of the design (strong, weak).
of clearinghouse include the American Speech-Lan- Several other clearinghouses aside from Co-
guage-Hearing Association’s Compendium of EBP chrane, Campbell, and What Works may also offer
Guidelines and Systematic Reviews (www.asha.org), information of relevance to speech-language pathol-
and The National Guideline Clearinghouse (www. ogy. The California Evidence-Based Clearinghouse
guideline.gov), an initiative of the United States De- for Child Welfare (www.cachildwelfareclearing-
partment of Health and Human Services’ Agency for house.org) is organized similarly to that of the What
Healthcare and Quality. Of the two types of clear- Works Clearinghouse and provides commissioned
inghouses, the former is the decidedly more useful reviews of topics related to child welfare. On the ba-
to the clinician engaged in evidence-based practice, sis of the available evidence, specific interventions
as it provides access to systematic reviews and meta- are rated for the strength of evidence (e.g., well-sup-

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 E vidence-Based Prac tice in Speech-Language Pathology: Scaling Up

ported by scientific evidence, lacks adequate research evidence may take a great deal of work and presents
evidence). Although many of the reviews available one of the largest challenges the clinician faces who
are not directly relevant to the speech-language pa- seeks to engage in evidence-based practice. Conse-
thologist, some may be informative to clinical prac- quently, structures must be put into place that en-
tice, such as the reports in the topic areas address- able the speech-language pathologist to readily ac-
ing Youth Transitioning into Adulthood and Parent cess and synthesize the relevant empirical literature
Training. The Coalition for Evidence-Based Policy and to consider its implications for a given clinical
offers summaries of well-conducted randomized question. These structures are what will permit the
controlled studies on a variety of topics through scalability of evidence-based practice, and include,
their Social Programs That Work clearinghouse in part, systematic reviews and meta-analyses, treat-
(www.evidencebasedprograms.org). Recent reports ment studies, and clearinghouses that together pro-
describe effects associated with the Nurse-Fami- vide useable reports, syntheses, and interpretations
ly Partnership (a home visitation program) and the of the scientific literature. Without these structural
Abecedarian Preschool project (an early intervention supports, it is unlikely that evidence-based practice
program). The Center for Data-Driven Reform in can be scaled up in a way that has positive impacts
Education offers summaries of scientific reviews in on practice. Future efforts regarding the promotion
its Best Evidence Encyclopedia (www.bestevidence. of evidence-based practice must focus not only on
org). Reviews concerning the use of technology to training clinical professionals how to engage success-
teach reading and approaches to promoting litera- fully in this practice, but also the building of those
cy in English Language Learners may be of inter- structures necessary for the field to successful tran-
est to speech-language pathologists. The Promising sition from relying on craft to one that relies largely
Practices Network offers the Programs That Work on evidence.
Clearinghouse (www.promisingpractices.net), which
offers summaries of efficacious programs relevant to References
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are organized into categories based on the apparent Sciences (2001). Evidence based practice guidelines for the
strength of evidence (e.g., proven programs, promis- management of communication disorders in neurological-
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speech-language pathologists may adhere when Evidence-Based Practice in Communication Disorders
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Laura M. Justice

with low back pain. Journal of Orthopedic and Sports Justice, L. M., Mashburn, A., Pence, K., & Wiggins, A.
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