If It Quacks Like a Duck, part 2

So why do people continue to use questionable therapy techniques? Well, for one thing, although ASHA officially does not endorse any products or techniques, some may assume that by granting CEU's, ASHA gives its imprimatur to a course (although ASHA specifically states otherwise in a disclaimer printed on all CE information).

But more commonly, Speech-Language Pathologists rationalize their use with an assortment of “reasons” like those below (note: all of these are actual statements by SLPs regarding such controversial techniques as DPNS and VitalStim). My responses follow each item:

• “We don’t have evidence for most of what we do”
  This is true, in that we have no large-scale randomized controlled trials of any therapy approaches, and a limited number even of lesser quality studies. However, this does NOT give us license to st start throwing therapy techniques around willy-nilly. In the absence of proof of efficacy, we must select approaches based on sound theory and on an understanding of the cause(s) of a particular patient’s dysphagia.

• “If it works for some people, then why not?”
  Along the lines of “do what works,” this reason actually has some merit. HOWEVER, you need to know WHO it works for (“people with dysphagia” is an unacceptably broad category), and preferably WHY it works. Just because it works for SOME people does not mean it should be attempted on ALL.

• “It’s something else to have in the ‘bag of tricks’”
  You can always add “stuff” to the bag. But why would you add something that is not truly efficacious? So that when you’re stumped you can fumble around in the “bag of tricks” and have all sorts of things to choose from; never mind whether they are likely to work, just so long as you look like you’re doing something? Something about this statement really bothers me. A lot. I think because it reduces dysphagia management/treatment to a series of “tricks” which are sorted through more or less randomly until you happen to hit on one that seems to work. So much for thinking scientifically.

• “We don’t get good results with traditional therapy”
  So you’ll take anything that comes down the pike instead? This is SO not a good reason. With this rationale, you could justify having the patient sing the ABC’s backwards, or hang upside down, or balance on one foot in the rain three times a day to cure his or her dysphagia -- because, hey, we don‘t get good results with “traditional therapy“, so why not try this? If a therapy technique actually has merit (i.e., good results), then of course you should use it (with the appropriate populations). You wouldn’t need to justify it by pointing to the poorer results of alternative techniques.

• “Personal experiences can frequently tell us more about a technique than any study can.”
  Is personal experience important? Yes. Is it valuable? Yes. Should it supersede the scientific evidence? No. Studies can be flawed. They are not perfect. They do not tell us everything we might want to know. But we should not just discard them in favor of subjective, anecdotal evidence. At least, not if we want to be making some kind of attempt at evidence-based practice.