My nugget of ASHAcon knowledge

Friday was my first day of the ASHA Convention. For reasons I can’t remember, getting to ASHAcon on Friday rather than Thursday seemed work better for scheduling. I was wrong and missed out on a lot of great courses. I also missed out on a few meet-ups of those in the SLP blogosphere and Twitterverse. A learned lesson and a tip for future ASHAcon newbies: if you’re going to make the most of your ASHAcon experience (and the hard earned money you spend to get here!), get here on here on the opening day. The regret, it burns!

At any rate, I’m digressing from what I wanted to share with all of you good SLP folks. If you’ve ever thought about going to a short course, but have wavered because the cost (or the three hour, no break commitment), I’m telling you to reconsider. Short courses, if you’re not familiar, are ticketed courses on specific topics, many of which are put together by ASHA’s Special Interest Groups. The courses are presented by an array of panelists, usually those who have gained celebrity status among the ranks of their professional colleagues and humble followers. The partnership between such presenters and researchers provides an enormous wealth of knowledge to attendees in a way that is easy to follow along and digest. Among the seminars that I attended, the short course was a highlight of mine.

The short course I attended was Exercise Principles: How Much, How Often, How Intense? I believe that because there is a relatively small amount of course work on dysphagia in our professional training, many clinicians feel that there are gaps in our translational knowledge, that is the link between the science and our clinical practice. This sentiment may not be true for everybody, but I certainly feel this way at times. For example, what happens to our muscles when they are worked during exercise? How, on biological level, do muscles become stronger (or weaker)? What type of muscle do we use during swallowing, and will that influence that type of exercise we tell our patients to do? These are the types of questions that any of need to answer once we are already practicing and it exactly these types of questions that were answered by some of the biggest names in swallowing research: Dr. Lori Burkhead, Dr. Cathy Lazarus, Dr. Heather Clark and Dr. Michelle Troche. All of these presenters spoke at ease with the audience, with an authority gained by their years of experience and research, and it couldn’t have been a more informative and humbling presentation.

Because I’m a dork and believe in open-source knowledge in science, I want to share with you some of what I learned. First, some basic info on muscle anatomy. The basic unit of a muscle is a myofibril, which are essentially strands of proteins. Myofibrils are made up of repeating pieces of sarcomeres, which are also strands of protein. When the motor neuron releases acetylcholine and it binds to the muscle cell receptors, the sarcomere contracts, which causes the myofibrils to contract and in turn the muscle at large also contracts.

myofibril

(Source. 1. Motor neuron. 2. Neuromuscular junction. 3. Muscle fiber. 4. Myofibril)

To strengthen a muscle, additional myofibrils must be built. In addition to this, there are two types of muscle:

  • Type I; these are fatigue resistant and are good for endurance
  • Type II; these are used for power and strength. This can be broke down into Type IIa and Type IIb, for moderate activity/efficiency and for high power/less efficient activity, respectively.

So why is this important to know for dysphagia rehab? Because form follows function. In large, the tongue is made up of Type II muscle fibers, with the base of the tongue predominantly made of Type II and the tongue tip having more Type I than any other part of the tongue. When a muscle deconditions, neural activation, motor neurons and efficiency are reduced, which translates to atrophy and easily fatigued muscles. Another important factor of deconditioning is the phenomena of sarcophenia, age related decline of muscle fibers. As it is, this largely affects Type II fibers, which we know is predominant in the tongue. Swallowing, we have a problem.

It can be argued, they said, that when a person becomes npo, this deconditioning occurs because swallowing frequency declines, which in turn exacerbates dysphagia. I think this is a valid working theory. Then the question becomes ‘how do we reverse this trend? The answer: by conditioning muscles. This almost exactly the opposite of deconditioning, by increasing neural activation and the number of motor neurons. And do this, exercise must be a component of treatment, and exercise must have some distinct characteristics.

First, exercise must be specific, meaning it should mimic what actually happens during the swallowing. Citing some examples from exercise physiology as an analogy, people who want to improve in cycling will bike as exercise, and these people will not see any improvement in other sports, like running or swimming. Intensity also matters, in fact, there are some rather specific guidelines for this. To build those myofibrils, ate muscle needs to be overloaded during an exercise, at at least 60% of the maximum output of that muscle. To prevent plateau, it’s important to recognize gains and new maximum output after exercise to maintain that 60% mark.

They also cited numerous studies highlighting specific exercise effects for the tongue with some novel findings. Exercising the tongue against resistance in a variety of directions (protrusion, elevation and lateralization) yielded stronger forces, no surprise there. But they also found that exercising the tongue in a single direction improved strength for tongue movements in all directions. To me, this seemed to deviate slightly from the specificity principle. However, in studying exercise conditions, they found specific effects for targeting strength, power and endurance of the tongue, all of which were mutually exclusive (i.e., targeting strength did not improve power).

A little more murky was the research regarding duration of exercise. Should exercise be done two times a week? Seven days a week? There seemed to be positive effects from anywhere between 2 and 7 days a week for at least 4 weeks or more. Though, no clear picture was really made on this point, other than exercising more often than not is important.

This was essentially the meat of the course. There was a lot more than this, of course, and I could write a much longer post than this if I wanted. The panel also discussed changes to tissues and muscles following radiation therapy for head and neck cancer, the importance of pre- and post-dypsphagia exercise and the time frame of when to expect improved muscle and swallow function. There was also talk on the use of expiratory muscle strength training (EMST) and its application to swallowing function. I was only vaguely aware of EMST in general, which is the use of a device into one blows against resistance to improve muscle respiratory muscle strength. As it happens, use of EMST also promotes soft palate and laryngeal elevation and base of tongue retraction-all things that happen during swallowing. Needless to say, I’ll be following research on this a little more closely in the future.

This short course was exactly what I look for when attending a seminar. It had knowledgable presenters who engaged the audience, it covered basic scientific concepts and in turn used that science to garner translational knowledge to bridge that gap between the lab and the clinic. Did anyone else attend this course? Please add anything you thought I didn’t cover, or something that I didn’t make more clear. Did you attend another short course, or another seminar that blew your mind? Let us know here. Drop the name of seminar, the presenter and what you took away presentation.

 

(Adam is one of the official ASHA Convention bloggers! Stay tuned for more insights from him and the other bloggers before, during and after convention.)

Adam Slota M.A., CCC-SLP is a speech pathologist working in long term care and long term acute care settings, primarily with tracheostomy and ventilator dependent patients. He is also the author of the blog slowdog where he writes about various topics in speech pathology and beer, among other frisky and/or mundane missives.

What are you planning at the ASHA Convention?

In about a week, I’ll be leaving the cold tundra that Chicago is about to become and heading to the temperate beaches of San Diego to, well, sit inside some conference rooms listening to the science that drives the professions of speech pathology and audiology at the 2011 ASHA Convention (ASHAcon). I’ve had the wonderful opportunity to attend ASHAcon several times in the past, but this is the first time that I’ll be blogging some of the ASHA goodies and sharing that ASHA love with you all via the interwebz, and I couldn’t be more excited to do it.

This year I’ll be looking at all things dysphagia. I want to know how exercise physiology impacts swallow function (what works and what doesn’t?), how to strengthen both bedside and instrumental evaluation of swallowing, ways to improve communication between long term care SLPs and hospital SLPs, among whole of host of dysphagia related goodness as it relates to stroke, head/neck cancer and neurodegenerative diseases. Yes, these are all topics that will be discussed at ASHAcon (and more!). Plus, this year I signed up for my first short course through Special Interest Group 13, Swallowing and Swallow Disorders (Dysphagia), entitled “Exercise Principles: How Much, How Often, & How Intense?” which I’m excited to attend to keep my practice in check with supporting evidence. There are also a few golden nuggets of tracheostomy related courses out there I hope to have time to attend. If I’m real lucky, I’ll find time get a seminar or two on some aphasia topics, a substrate of speech pathology that I desperately need a refresher in.

Are you planning on attending ASHAcon? Then share with us what courses you’re looking forward to attending, or what topics you just can’t wait to learn more about here in the comments. Did you take a mind blowing course at a previous ASHAcon? Then share the wealth with us! And if you’re planning on attending some dysphagia seminars, make sure to hi. I’ll be the guy. If there’s more than one of us there, I’ll be in jeans, furiously taking notes, tweeting and blogging on an iPad (or stuffing the raffle box for a chance to win a Subaru). Whether you go to ASHAcon or not, do make sure to follow convention news and updates here at ASHAsphere or follow ASHAcon on Twitter at @ASHAconv along with the #asha11 hashtag to keep up with all the delicious speech, language, hearing and swallow science.

(Adam is one of the official ASHA Convention bloggers! Stay tuned for more insights from him and the other bloggers before, during and after convention.)

Adam Slota M.A., CCC-SLP is a speech pathologist working in long term care and long term acute care settings, primarily with tracheostomy and ventilator dependent patients. He is also the author of the blog slowdog where he writes about various topics in speech pathology and beer, among other frisky and/or mundane missives.

Thoughts on ‘Apps for Autism’

iPad on Tanmay's jeans


Photo by Chirantan Patnaik

First a disclaimer: I don’t work with patients with autism, in fact I haven’t done so since grad school, and even then I only worked with the population sparingly. iPads on the other hand, are awesome, and I use mine daily (much to my wife’s chagrin) for nearly everything (including this post) besides treatment (unless you count documentation, for which I use an iPod Touch), and that’s only because it doesn’t make much sense for my setting, not yet anyways (this is the point where I stop making parenthetical statements). But I am a speech pathologist and I do know a thing or two about communication, and that’s why I watched last Sunday’s 60 Minute segment, Apps for Autism, with much anticipation and excitement. I generally have respect for the show, but at the end, I just felt ‘meh’ about the whole piece. And let me tell you why.

When you watched the segment, did you notice the peeps with autism struggling and ultimately failing to use paper letter boards to communicate, which was immediately followed by the same person using the iPad exceptionally well to convey their message? This scenario was shown a few times throughout the piece and it felt like an As Seen On TV infomercial. Besides that, it completely ignored the decades worth of research and development that has been done in the field of Augmentative and Alternative Communication (AAC). It’s as if the Lightwriter, Dynavox, Prentke Romich, Tobii-along with a host of other companies-devices have never existed. That the idea of using technology to help people communicate is one that is original to the iPad. And that, of course, is rubbish.

It also seemed to prescribe the iPad as a panacea for autism treatment, you know, just give the kid an iPad and he’ll be on his way to communicating and that it’ll unlock an new and undiscovered portal into their minds that we never knew existed. Forget the fact that the successful use of AAC devices require training, especially for those with cognitive deficits, and forget that speech pathologists and special education teachers are needed to foster language development and literacy skills in order for the iPad to even be a viable option. A Twitter friend, @JohnduBois, said it right: “I felt it ignored the point that AAC is a tool and requires proficient users and teachers-too much “Apple magic”. Indeed sir, indeed.

And what was with that lady doing hand-over-hand assistance with the kid who had no apparent interest in the task? It was way too reminiscent of facilitated communication, and we evidence-based practitioners do no want to go there. Most likely, and hopefully, she was simply providing cues and trying to engage the kid in activity, but I cringe at even the slightest hint of FC.

For all of 60 Minute’s shortcomings, it must be said that the iPad is most definitely an inspiring piece of technology, and it is capable of capturing the attention of of children and adults alike with its boundless applications. But we need to be mindful that when teaching social skills to children, we teach them to use turn-taking skills, theory mind and what have you with people and not machines. If a child is captivated by the iPad and is able to direct their attention to something purposeful and meaningful, that’s great, but its all for naught if those skills do not generalize to the world at large.

The iPad is a wonderful and powerful tool, and has numerous applications for autism treatment, and the broader speech pathology and special education fields as well. But let’s place our focus on the end goal and not the bright and shiny gadgets that serve to facilitate such goals, lest we become victims of the latest fad and fail to view the iPad for what it is: a tool.

(This post originally appeared on slowdog)

 

Adam Slota M.A., CCC-SLP is a speech pathologist working in long term care and long term acute care settings, primarily with tracheostomy and ventilator dependent patients. He is also the author of the blog slowdog where he writes about various topics in speech pathology and beer, among other frisky and/or mundane missives.

 

 

Dear Patient

365: 31 -  31.01.09


Photo by Foxtongue

Dear patient,

When you were admitted to my facility I was literally heading out of the door to go home and relax for the evening. I probably planned to have some dinner, read and maybe if I was lucky I’d have a good beer to round out the night. But on my way out I was flagged down by a nurse saying that you wanted to drink regular, thin water.  Actually, the nurse said that you were demanding and yelling about it. At this point, I had no idea who you were; I had no idea we even had any new admissions.  So, I put down my bag and made my day a little longer to see what the buzz was about. I know this isn’t your fault; you probably had little control over what time your transfer took place, and even if you did, I was probably the last person on your mind, but probably not even that. There’s a good chance it didn’t register with you that you’d be seeing someone like me. I don’t mind, and since I like my job and I care about your well-being I came straight to your room without even looking at your chart, something I almost never do, to have a little chat.

As I came into your room I noticed right away that you had a trach. I introduced myself and explained my role as the person who works with swallowing and diet modifications, among other things. Without an acknowledgement of who I was, you began to curse and yell at me that you wanted water and that your previous speech pathologist at the other facility let you have ice chips and water. Not that I expected anything less; you’ve been through a lot, I’m sure, and you’re just trying to advocate for yourself. I get it. And I actually believe everything you told me, but being diligent with my duties and to ultimately look out for your well-being I needed to look through your medical chart to get a better sense of your history and to see if there was any information to clear up this misunderstanding.

After you made your needs known to me, I checked your chart. Your transfer order stated that you should have honey thickened liquids. I found no notes from your previous speech pathologist and no other indication that you were allowed water and ice chips. I also learned you had a PEG and some other conditions that put you at risk for swallowing difficulties. Not to mention you have a trach which adds another level of potential problems. Believe it or not, I still believed what you said about about drinking water and having ice chips but that doesn’t mean I can just change your diet.

I came back to your room to tell you what I learned, but before I could explain what this information meant, you flipped out at me, continued to curse at me and demanded that you be allowed to have thin liquids. Obviously you knew where I was going with this conversation. Between your outbursts, I did my best to explain that even though you may have had thin liquids at your last hospital, you came here with a honey thick liquid restriction and that I couldn’t find anything in your chart that indicated you were able to drink thin liquids safely, that is, drinking thin liquids without it entering your lungs. I couldn’t even find a single note about thin liquid trials with your previous speech pathologist. I don’t blame you for how you felt, nor did I get upset about it. Even though I work with dysphagic patients every day, I still can not fathom what it would be like to not drink what I like, on top of that, having a stranger tell me what I can and can not drink. That would totally suck. I once even tried to drink the stuff we give you. Its gross, and I couldn’t imagine drinking that stuff with every meal. That would also totally suck. I could see you were upset because you kept swearing at me. You really do have some foul language! I still don’t blame you, because your situation is awful and I can imagine myself acting very much in the same way. So, as a last ditch effort I called your last hospital but could not get a hold of anybody in the speech department or anyone in nursing who could clarify what your diet was. So honey thickened liquid remained your diet for at least that night.

You see, I did everything I could to determine if thin liquids were safe for you. I do care; I empathize with you, because I do not envy what are going through. But I have to make my decisions not based on entirely what you want, but based on the data I have about you. I believe you when you say you had water and ice at the last hospital, but I have no way to verify that. I don’t have the tools at my immediate disposal to determine if you can drink water without it going into your lungs. You came to my building with a honey thick liquid restriction and that will remain until I can verify that you are safe for thin liquids, whether it be a report from your previous speech pathologist or passing a video swallow eval. This isn’t because I’m a jerk, even though you might think I am-its because I actually do care and I don’t want to make a careless decision that could land you back in the hospital with pneumonia. Pneumonia will undoubtably prolong your course of hospitalization and it will add quite a bit of money to your bill. Not to mention that aspiration pneumonia is life-threatening. You could die if I mindlessly changed you to thin liquids. That is simply a risk I won’t make. Not just for you, but for any of my patients.

You seem like a good person and I do look forward to working with you. I look forward to hopefully getting rid of that nasty honey thick restriction and seeing the happiness and relief on your face when you hear the good news. I want you to avoid getting sucked into the blackhole of health care, bouncing between hospitals and skilled nursing facilities for preventable issues. Instead, I want to see you go home healthy and fit so you can live a happy life. I hope that you realize I’m not some dolt, but someone that does genuinely care about your health.

Your Speech Pathologist,
Adam

(This post originally appeared on slowdog)

 

Adam Slota M.A., CCC-SLP is a speech pathologist working in long term care and long term acute care settings, primarily with tracheostomy and ventilator dependent patients. He is also the author of the blog slowdog where he writes about various topics in speech pathology and beer, among other frisky and/or mundane missives.