7 Clues in the Medical Record to Discover Dysphagia

7 clues

Medical speech pathology has its uncertainties.This may cause the speech-language pathologist to be very conservative, possibly over-treating or overcompensating, per James Coyle, PhD, CCC-SLP, BCS-S at his talk on April 11, 2014, at the ASHA Healthcare & Business Institute.

“When the cause of dysphagia is not obvious: Sorting through treasure and surprises in the medical record.”

Coyle advised clinicians to value the medical record just as much as our direct examination of the patient. The “medical record is a messy place,” per Coyle. It is our job to dig for clues to distinguish which came first: the illness or the dysphagia. Some conditions can mimic dysphagia-related aspiration pneumonia. Some community acquired infections can create weakness and delirium, which then cause an acute dysphagia.

Let’s start with a story: An active-independent elderly female develops a urinary tract infection (UTI). She feels sleepy and stops eating/drinking regularly. This worsens the UTI and causes dehydration. She gets to the hospital four days after the onset of symptoms. Dehydration causes electrolyte imbalances, leading to delirium. Delirium + infection = more lethargy and a global cognitive decline. Being out of her usual environment causes more confusion and agitation. Antipsychotic medications are used to control the acute agitation. The patient becomes septic, as the infectious process spreads. Her urosepsis spreads to a pneumonia. The SLP notes a high aspiration risk, as the patient looks severely impaired. Unfortunately, without a thorough medical record review, the patient is labeled with dysphagia-related aspiration pneumonia. She stays on thickened liquids and pureed foods until hospital discharge. Will the patient fall through the cracks and never eat regular food again? Will the “Big-A-word” (ASPIRATION) follow her the rest of her life? Or will an SLP re-evaluate her in two weeks and discover that her dysphagia has disappeared?

I have summarized Coyle’s talk into these seven clues (more details and references in my full post).

1)    Is it pneumonia?

  • New infiltrate on CXR. Dependent lobes? Not necessarily only the lower lobes if the patient is bedridden or aspirating while laying down on the couch.
  • Leukocytosis (WBC count of >11.5-12.0). Warning: immune-compromised patients cannot make white blood cells.
  • Fever (>38 Celsius for >24 hours)

 

2)    What type of pneumonia is it?

  • Ventilator Acquired Pneumonia (VAP): May be widespread infiltrates. Strong correlation with oral pathogens.
  • Dysphagia-Related Aspiration Pneumonia (DAP): A recurrent pneumonia may be one big infection from ongoing aspiration. Perform a swallow study to determine if dysphagia is present and why. This is so important. If we label them with DAP, that patient’s past medical history will forever say “Aspiration Pneumonia.” Then medical personnel may be overly conservative in the future.
  • Non-Dysphagia-Related Aspiration Pneumonia (NDAP) and/or Aspiration Pneumonitis: if no dysphagia present before infection, check history for chemical irritants, allergens, reflux, a vomiting event, or use of acid-suppression therapy (i.e., Proton-Pump Inhibitors).
  • Hospital Acquired Pneumonia (HAP) or Health Care Acquired Pneumonia (HCAP): pathogens from the institution getting into the lung. Aspiration?
  • Community Acquired Pneumonia (CAP): may be diffuse infiltrates and not in dependent lobes.

 

3)    What was the patient’s baseline? “You got to have dysphagia to have dysphagia,” joked Coyle. “But seriously,” he added, “I can’t underscore this enough.” Dysphagia-Related Aspiration Pneumonia (DAP) requires the finding of difficulty swallowing prior to getting sick. Be a detective.

 

4)    Is there a systemic spread of infection (e.g., septicemia or sepsis)?

  • Sources: The lung is not the sole source for the primary infection. Wound, oral cavity, urinary tract?
  • Problem: The patient may not develop sudden signs, but it can unfold rapidly. Coyle urged SLPs to be careful when predicting goals for the future, as “sick people look pretty darn sick.” Good communication is needed at discharge to ensure re-evaluations.
  • Ask the medical team questions: Is this a short-term reversible problem? Could this be an acute dysphagia due to the illness?

 

5)    Was there a surgical procedure that could have caused the dysphagia? For examples: cardiothoracic surgery, lung transplant, lung resection, esophagectomy, head/neck cancer resection. Coyle recommended Atkins, et al (2007). See references on my full post.

 

6)    Was there a medical procedure that could have caused the dysphagia or an aspiration? For examples: feeding tubes, prolonged intubation, traumatic intubation, peri-operative aspiration event, chemotherapy/radiation.

 

7)    Are there medications that could be causing the aspiration, dysphagia, or pneumonia?

  • Polypharmacy increases a patient’s pneumonia risk.
  • Coyle recommended reading Knol, et al (2008). This was a case controlled study of elderly patients with age-matched controls. Patients who received antipsychotics where 60% more likely to have pneumonia.
  • Read more possibilities on my full post.

 

Our answers to these questions have a great impact on all we do: from our initial examination and instrumental evaluations through our discharge plan and beyond. SLPs do not diagnose pneumonia, but our communication with the medical team is an extremely valuable contribution to their differential diagnosis.

 

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995 with her master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr. John (Jay) Rosenbek, Dr. JoAnne Robbins, and Dr. James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. Karen has always enjoyed medical speech pathology, working in skilled nursing facilities and rehabilitation centers in the 1990s, and now in acute care in the Boston area for more than 14 years. She has trained graduate student clinicians during their acute care internships for more than 10 years. Special interests include neurological conditions, esophageal dysphagia, geriatrics, end-of-life considerations, and patient safety/risk management. She has lectured on various topics in dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. You can follow her blog, www.swallowstudy.com.

 

Collaboration Corner: Surviving Dysphagia in Schools

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(photo credit)

According to ASHA (2006), 1 in 10 public school speech-language pathologists have a student with dysphagia. I have to be honest; this is a struggle for me. Here’s why: while I have extensive dysphagia experience in medical and private home-based settings, I have difficulty defining my role as an SLP who provides dysphagia therapy in school.

Identifying the obstacles

ASHA has a fairly clear document describing the role of the school-based SLP in schools. However, the perceived obstacles can be daunting (Miller, 2008). The top 4 obstacles consistently come across are: Scheduling and environment, training staff, keeping the lines of communication open between family, staff and outside therapists, and getting student buy-in.

Removing the obstacles

Miller (2008) urges collaboration in treating students with dysphagia. I have the good fortune to work with many talented special educators, nurses, behavior specialists. While I bring the knowledge of dysphagia to the table (bad pun), recognizing the daily demands upon the child requires team-based attention. The following strategies may help balance your student’s dysphagia issues within the context of the school day:

Examine/modify the child’s schedule. Students have very little time to eat. Snack is usually 15 minutes (if at all) and lunch is about the same with recess either before or after. This means students risk missing academic time, social time, recess. Suddenly speech is the no fun allowed zone; staff/students become worried that therapy cuts into these activities.

To help with this let the child start eating in the cafeteria before everyone else arrives, use calming strategies such as music with headphones, or a favorite book for the child to read while he/she is eating. Bring a lunch buddy if it helps. Gradually set limits around how much music she/he can listen to. If a child is too overstimulated during lunch time (elementary cafeterias are quite an experience), have the student eat early and let them read a book or chat with friends. This allows mealtimes to be associated with positive feelings.

Training staff. Many students have a paraprofessional, who also needs to eat their lunch, but guess when their student may need the most support? During lunch, of course. Keep clear instructions and provide hands-on training for staff, give a copy to the school nurse. If there is a change in staffing, make sure the change is with a familiar person who also has training. I have staff sit in on times that are not during their break or lunch. I also encourage the student’s paraprofessional to eat with the student as to “normalize” the experience and to provide role-modeling around food. We have Fun Friday where everyone eats together and we do a fun food play activity. Again, create positive associations with eating (for staff and students!). Staff need consistent access to strategies that will keep the student calm, like this cue card, created by my colleague and co-author of The Behavior Code:

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Communicate closely with families. Eating is a cultural and emotional experience. Ongoing communication with family members provides insight as to when everyone is ready to move to the next step. Clearly communicate that safety is the most important factor in the decisions related to their child’s eating. Encourage parents to come in, or take pictures and video. Use a home-communication journal so notes can go between school and home, highlighting what they ate, how much they ate, and any events that may have affected their eating.

Communicating with outside SLPs. OK, so here’s the deal. Expertise exists across settings. If I don’t do VFSS  on a daily basis, I recognize that I am not an expert in that assessment tool. But if I have a background in dysphagia, have worked in schools for 11 years, have seen this student 3 times a week in their school setting for three years, guess what? I have expertise as well. I can (and should) make a referral for a VFSS by an SLP who has the skill and equipment. Likewise, private SLPs should confer with the school-based SLPs perspectives on eating. Speech-language pathologists need to reach out to one another and value these differences. These differences are a good thing (stepping off of my soapbox now….).

Make the child a part of the process. Keep it low pressure, and rewarding. Take picture of their successes and make a book about it together.  Have them review the book before they eat, so they remember their successes and eating strategies. Here’s a rather crude (but effective) example of a page I wrote with my student:

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Last but not least, set aside your own assumptions of what tastes/feels/smells good….these kids experience food much differently than you do. Remember, eating involves developing trust; it is not a forced process. The end goal is to make eating pleasurable and safe so that mealtime becomes enjoyable for everyone.

Dr. Kerry Davis is a city-wide speech-language pathologist in the Boston area. Her areas of interest include working with children with multiple disabilities, inclusion in education and professional development. The views on this blog are my own and do not represent those of my employer. Dr. Davis can be followed on Twitter at @DrKDavisslp.

Tiffani Wallace’s 2012 Top CEU Courses, Books and Apps Related to Dysphagia

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2012 was full of a lot of new experiences for me.  I was approached at the beginning of the year to begin speaking on dysphagia for PESI.  My first speaking engagements were in North Carolina in December.  I absolutely loved it!  Granted, I still have some kinks to iron out in the professional speaking world, but all in all, I thought it went pretty well.  I can’t wait for my next speaking engagement in January down south again, then in Illinois in June. I continued work on my BRS-S and finally was accepted!  Not only accepted, I passed my test!  I can now officially put BRS-S after my name.  Such long-sought and hard-earned letters!

Soon after I earned my BRS-S, I was promoted to Rehab Director of our department.  I’m still learning the ropes and working on improving our department.  I love the new job duties though.

I went to ASHA and had the opportunity to visit old friends and meet new friends.  As always, I had such a fun time!  I again had the opportunity to present a poster session.  It had a great turnout.  I worked in the SmartyEars booth, which is so much fun.  It’s always great to meet people and show off SmartyEars apps.  I always feel a lot of pride when people want to see a demonstration of Dysphagia2Go.  I would love to say that I attend the ASHA convention for the CEU’s, but I attend for the socialization.  That is one week of the year I feel like I am in “SLP heaven”.

I decided to end this post with a list.  Everyone always wants to know my recommendations.  Here are my top CEU courses, books and apps related to dysphagia.

Top CEU courses:

The VitalStim course by CIAO seminars is invaluable.  It’s absolutely great information, with such a huge emphasis on anatomy and physiology.  It is definitely worth the price whether you use the device or not.

MBSImP course by Bonnie Martin-Harris, provided by Northern Speech Services is another outstanding course.  Again, this course is based on the anatomy and physiology of the swallow and using it in interpretation of Modified Barium Swallow Studies.

Of course, my Dysphagia course.  I like to think that it is full of invaluable information.  :)

Top Books on Dysphagia:

Dysphagia Following Stroke by Stephanie K. Daniels and Maggie Lee Huckabee is absolutely excellent.  I’m in the process of re-reading it.  It is a book I will keep.


Drugs and Dysphagia
.  Great reference.


The Source for Dysphagia
by Nancy Swigert is my bible.  I love that book.


Clinical Anatomy and Physiology of the Swallowing Mechanism
.  Absolutely must-read!!


My Top Apps for Dysphagia

Of course my top vote goes to Dysphagia2Go.  I use this app all the time when I do a clinical evaluation of swallowing.  It lets me input all my data and then allows me to print a report of my findings.  This app is available for $39.99 on iTunes.

Dysphagia by Northern Speech Services costs $9.99 and offers amazing pictures of swallowing and swallowing deficits to share with your patients.

Lab Tests is a $2.99 app that allows you to look up lab values, their meanings and why the tests are performed.  This app does not require wi-fi to run.

Micromedex is a free drug app that is amazing and gives you not only information about the drug, but possible side effects, warnings, etc.  You can look up virtually any drug.

Cranial nerves is a $2.99 app that gives you information on all 12 cranial apps.  Not only does it give you the in-app information, but also allows you to, with the push of a button, access further information on the app on Wikipedia and Google.

 

I hope everyone has an amazing 2013.  I so look forward to all the new and great things to come!

This post is based on a post that originally appeared on Dysphagia Ramblings.

Tiffani Wallace, CCC-SLP, has been an SLP specializing in Dysphagia for over 11 years.  Tiffani has been very active in the social media world, creating 2 Facebook groups, Dysphagia Therapy Group and Dysphagia Therapy Group-Professional Edition.  Tiffani is also the co-author of the app Dysphagia2Go, available on iTunes.  She is preparing to travel nationally and speak on the topic of Dysphagia.  Tiffani writes a blog called Dysphagia Ramblings and is the author of www.dysphagiaramblings.com.  She is a 5 time ACE awardee and recently obtained her BRS-S.

It Really is a “Brave New World” for Speech-Language Pathology!

In 1931, Aldous Huxley’s novel A Brave New World told us a tale of what society in the distant future would look like… a place of advanced technology, new social structures and radical changes in how humanity interacts with each other… sound familiar?

Well, arranging the Georgia Speech-Language Hearing Association’s (GSHA) short course offerings has opened my eyes to how very fast the role of being an SLP is changing from year to year. We are now serving highly diverse populations of multiple nationalities, utilizing technology that just 10 years ago was science fiction and becoming more and more an integrated part of the healthcare community in general. From NICU to hospice, home health care to the public schools, SLPs are involved with communication and swallowing disorders across the lifespan. We are providing these services in a cost effective, evidence based manner that is making real and measurable change in the populations we serve.

It is with this “Brave New World” in mind, that GSHA would like to present to our fellow convention-goers three short course opportunities that are sure to make a positive impact on the clients, patients and students we all serve. ASHA has given the Georgia association the wonderful opportunity to provide ticketed pre-convention and convention related short courses on November 14th and 15th. Please join us on November 14th for-

Barbara Fernandes, M.S., CCC-SLP The iPad and Your Therapy – Apps, Accessories, Accessibility and Features

Jose Galarza, M.A., CCC-SLP Spanish Influenced English: What Every SLP Should Know

and on November 15th for-

Kate Krival, Ph. D. CCC-SLP Anticipation: Neural Bases and Clinical Implications in Swallowing in Adults

Our pre-convention activities on November 14th will include presentations from Barbara Fernandes, M.S, CCC-SLP and Jose Galarza, M.A. CCC-SLP. Barbara (better known as GeekSLP) will be presenting on all things Apple, Ipad and App related. Bring your Ipad and/or Iphone to her presentation and you will leave better understanding how to use it with your respective population. Jose’s presentation will address the needs of monolingual SLPs working with bilingual children in the school setting. Since school SLPs are increasingly faced with the communication needs of Hispanic children, his presentation is especially relevant to the English speaker attempting evaluation and treatment of those children. Barbara and Jose are both experts in their respective areas and will highly impact the attendee in a positive manner.

On November 15th, join GSHA in welcoming Kate Krival, Ph. D., CCC/SLP. Dr. Krival directs the Swallowing Research Lab at Kent State University and she is a Research Investigator in the Head and Neck Neural Interface Lab at Louis Stokes Veterans Administration Medical Center in Cleveland, OH. She is particularly interested in clinical research targeting sensory-based interventions for swallowing disorders in adults with neurogenic dysphagia. If dysphagia is your area of interest, Kate will leave you with tons of evidenced based ideas for use with your patients!

So, Join GSHA and ASHA in facing this Brave New World of ours with the confidence that these courses will keep you informed, up to date and ahead of the curve!!! See you in Atlanta…

 

Edgar V. (Vince) Clark, M. Ed., CCC/SLP, advocates for the importance of state association participation whenever possible. He is currently the GSHA to ASHA Liason for the 2012 convention, current GSHA CEU chair and is a past-president of GSHA. Professionally, he is interested in adult dysphagia, all things technology, and the use of social media for promoting the professions.

 

The ASHA Convention is quickly approaching! If you haven’t already registered, don’t delay–register today! Stay tuned to ASHAsphere in the weeks leading up to the ASHA Convention for posts by the official Convention bloggers–Jeremy LegaspiTiffani Wallace and Katie Millican. Not an official Convention blogger but want to write a post about it for ASHAsphere? No problem! Send posts to Maggie McGary at mmcgary@asha.org and it could be featured here.

Using Your iPad in Dysphagia Therapy

iPad fascination

Photo by rahego

So many people are using iPads, iPhones and iPods in therapy. While there are many other devices out there, I’m focusing on the “iDevices” because those are the devices that I know the best. It is very easy to find apps for pediatric speech therapy, even apps for adult language therapy. There are apps for language, articulation, AAC, voice, fluency, and a few for dysphagia, but not many. It seems that few therapists are using their devices for dysphagia therapy. In lieu of the small number of apps available for those of us specializing in dysphagia therapy, we can very effectively use our iDevices for treatment.

One feature that comes with any of the iDevices is the notepad. This looks like the yellow legal pads that I’m sure we’ve all used. You can use the keyboard or dock your device to a keyboard to type notes. Once these notes are done you can then choose the option to print or you can email it to yourself to print. You can also use Evernote (which is free) to create documents and access everything from any of your smart devices or from the computer.

I use Dropbox quite often. Dropbox is a cloud storage app. I have it installed on my computer, iPad, iPod and Android phone. I save files from my computer including journal articles, forms, documents, etc and can access them through any of my mobile devices or can access them via the internet on any computer. In addition to Dropbox (which is free for 2 gb), I use Carbonite. Carbonite is a yearly subscription (around $60 a year) that is a backup system for your computer, it backs up all of your documents, plus you can log onto your account from any computer via the internet to access all of your backed-up items and there is an iOs and Android app to access your files from your mobile device.

Dysphagia2Go is the new Dysphagia evaluation app that lets you use your iPad during your Clinical Dysphagia Evaluation to write a report with all of your findings. If you already have a computerized version of your report, you can email the results to yourself and copy and paste your findings. This app is available through SmartyEars and will have some exciting new updates soon!

iSwallow is available for Apple devices. iSwallow is a free app that allows you to show videos of each exercise for your patient and allows your patient to track their exercises and lets the therapist see how many times each exercise was completed at home. This hasn’t been a very functional app for me; fortunately it was free. You have to email the company to get a password to unlock the app and I tried many times, unsuccessfully, to get the password from them. Fortunately, I ended up finding another therapist that had the password to get it. Also, it would be helpful if you had patients that owned iDevices so that they could utilize it. At this time, I’m not willing to loan out my devices to allow patients to track. Most of my patients are 70 or older and don’t own iDevices.

Lingraphica offers 2 apps for dysphagia. One is a communication aid for the iPhone/iPod Touch that can also be used on the iPad. It allows a patient with dysphagia to communicate regarding their dysphagia, for example, “I need my dentures” or “I need to be sitting up to eat”. This would be helpful if you have an aphasic patient with dysphagia that would be able and/or willing to communicate these items with others. Lingraphica also has an oral motor app which has videos of each exercise being completed.

There are also several apps which show the structures, from a scope view. You can use iLarynx, LUMA ENT and URVL to look at the structures, or to use for patient education. They are also fun to play and see if you can “insert” the scope appropriately.

Lab Tests is a relatively inexpensive app, I think it’s $1.99 that describes the lab values and has normative data for lab values. This is nice if you work in an acute care hospital, where they typically draw daily labs to interpret what the lab values indicate.

Pill Identifier lets you search medications by shape, color or score. Telling you what the pill is, what the indications are, how it is available OTC or prescription. You can view images of the pill or look at information of each pill via Drugs.com.

3D Brain is a wonderful view of the brain to educate patients on lesions and where their lesions are located. It’s also a fun app to play with giving you views of the brain and descriptions of the areas of the brain.

I’m sure this is not a comprehensive list of the apps however, hopefully it’s a start to help you utilize your iDevice in your dysphagia therapy. Also, keep watching SmartyEars for possible new dysphagia apps.

 

Tiffani Wallace, MA, CCC-SLP, currently works in an acute care hospital in Indiana.  Tiffani is working to specialize in dysphagia and is working to achieve the BRS-S.  She is also a member of the Smarty Ears Advisory Board and co-author of Dysphagia2Go, and has a website about dysphagia, Disphagia Ramblings.

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.

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.

Recent Dysphagia Surveys

(This post originally appeared on Dysphagia Ramblings)

I have often wondered what others that work in the area of dysphagia do during therapy.  I always want to know what tools they use and what books they recommend, so I made a survey.  Actually I made two.

First, I sent out 75 surveys, in the surrounding areas in Indiana (mostly central).  I received 13 of the surveys.  Ok, 12 because technically I did one as well.  Most of the surveys came back to me partially completed.  I have the results posted on Scribd.

As a whole, we had an average of 10 years of practice, with the shortest time being 2 years and the longest being 30 years or more.  Most therapists work in a SNF (Skilled Nursing Facility).  One concerning factor for me was the lack of use of a standardized bedside assessment.  In our realm of changing and more evidence-based therapy/healthcare, can we really continue to afford to use only our judgement with no real data to back up our findings??

Another concerning finding to me is that the most widely used therapy technique is diet alteration at 85%, which tied with oral exercises.  Perhaps, a new survey should be devised to determine what people consider oral exercises.  I realize that in SNF’s there will always be those patients that require a diet change and are not appropriate rehabilitation candidates, however SNF’s are also becoming widely known for rehabilitation.

Techniques that actually engage the swallowing function and tax the system to bring about an actual change, such as the Mendelsohn, the effortful swallow, etc, were only reported to be used 46-38% of the time.  I guess this would also explain why the average percentage of return to a normal diet was only 50% with most likely, spontaneous return accounting for some of the return.

Expiratory Muscle Strength Training (EMST) is an emerging therapy incorporating respiration strengthening with swallowing exercises.  Items such as The Breather were only incorporated into therapy by 1 therapist.  Of course, keep in mind, this was a very limited survey response, it still, I believe, paints a big picture of how our therapy looks.

With the limited number of surveys that were returned to me per mail, I decided to also create a survey by Survey Monkey.  This survey had a response from 44 therapists.  Again, the majority of the therapists from this survey work in a SNF.  The most widely used therapy “tool” is tongue depressors.  I’m guessing because it’s the most accessible tool we can get.  The Breather/Spirometer for EMST was still fairly low on the list with 14-17% usage and the Iowa Oral Performance Instrument (IOPI) was at 9.5%.

Again, the most popular therapy technique is diet alteration at 95%.  Some of the rehabilitative strategies we use such as the effortful swallow, Mendelsohn, etc.were used by 50% or more of the respondents.

I think that one important thing we can learn here is that diet changes, head turns, chin tucks, double swallows are not “rehabilitative”.  They create a safe swallow for the present time while we rehabilitate the swallow for a diet upgrade.  While we may have our patients on an altered diet or have them employ compensatory strategies, we also need to work the patient, use that effortful swallow, the Mendelsohn.  Work the swallow system and make it work like it should.  That is rehabiltiation.  When we bring about a change, we rehabilitate.

Most of us do recommend The Source for Dysphagia by Nancy Swigert as our favorite book.

I think the main thing we need to ask ourselves when treating our patients with dysphagia is, “Am I doing everything I can to rehabilitate my patient?”  Then ask yourself do you feel comfortable in saying yes you are.  Treat your patients as you expect to be treated.

Tiffani Wallace, MA, CCC-SLP, currently works in an acute care hospital in Indiana.  Tiffani is working to specialize in dysphagia and is working to achieve the BRS-S.  You can find Tiffani’s blog at http://apujo5.blogspot.com.