(Music fade in)
J.D. Gray: This is ASHA Voices. I’m J.D. Gray.
What’s a better social experience than sharing a meal with our friends and family? It’s tied to some of our best memories—weddings, birthdays, holidays…
Unfortunately, if you struggle with swallowing—known clinically as dysphagia—sharing a meal may be impossible. But some patients may be able to get back to the dinner table using techniques taught by speech-language pathologists.
SLP Lori Burkhead Morgan helps those with dysphagia regain their swallowing skills using exercises which improve strength, speed, coordination, and endurance.
Lori Burkhead Morgan:
“We now have tools that help us really engage the patient and help us figure out how to do something other than just swallow over and over again, and hope it makes us better.”
Gray: Lori shares her how her time studying exercise science in Florida led her to rethink how she guides treatment exercises.
And, later in the program we’ll talk to Purdue University’s Georgia Malandraki. She recently published a paper on the research she’s doing into wearable dysphagia trackers.
Finally, we’ll round out the program with a conversation with Emily Homer. She sits down with us to discuss how school districts can provide swallowing and feeding services.
I’m J.D. Gray, and this is ASHA Voices.
(Music – ES_Typewriter Song)
Support for ASHA Voices comes from ASHA’s online conference Innovative Methods for Preschool Assessment, Collaboration, and Treatment. This continuing education opportunity begins February 19. Learn more at on-dot-asha-dot-org-slash-preschool.
Support for ASHA Voices also comes from ASHA Professional Development. Call for posters for ASHA’s 2020 Connect Conferences is open now through February 12. Submit yours today.
Gray: When treating dysphagia, how often do you find yourself thinking of exercise science? Or workouts and athletics? Burkhead Morgan Burkhead Morgan does.
Lori Burkhead Morgan is an SLP, and faculty at the Medical College of Georgia at Augusta University. She also teaches at University of Georgia in Athens. I spoke with her at the 2019 ASHA Convention.
She shared how concepts like frequency, intensity, and specificity can be used to improve dysphagia treatment. Lori combines years of experience as an SLP with her studies of exercise science. I started by asking her, “What does exercise science have to do with dysphagia treatment?”
Burkhead Morgan: In dysphasia treatment we’re often charged with working with weak muscles, or working with movements that are not quite right, to help patients swallow safely, keep things out of their airway, or windpipe. And so what better way to exercise, than to look at our colleagues in exercise science, sports training, physical therapy, and see how or if any of that might apply to the swallowing musculature? So that’s what I do.
Gray: So what was it that made you take a look at dysphagia treatment through this lens?
Burkhead Morgan: Well, as an in-the-trenches speech pathologist for many years before I went back to get a PhD, I was frustrated. I was looking around at my PT and OT colleagues who were doing really prescriptive therapy exercises. They actually seem to have an idea of what they were working on, as far as strength, or coordination, or speed, or endurance. And all I had in my arsenal was, “Swallow, swallow harder. I kind of think that was harder. Do you think that was harder?” And sometimes the patient would think it was, and I didn’t. And so I just felt like I was shooting in the dark. I had a variety of exercises to do, but without a real background in exercise science, I didn’t know really how to apply them, or if I was making a difference.
Gray: Tell me about some of the exercises that you would use that you couldn’t really measure in the way that you might measure something with exercise science.
Burkhead Morgan: Exercise science tells us that we need to do exercises in a way that is intense enough to force the nerves and muscles to have to change, to adapt. And I think one thing was, we didn’t know how hard we had to work patients, and we weren’t. And the bleeding-heart speech pathologist was saying, “Oh they’re working so hard. I let them just stop, because it was getting hard for them.” When in fact, that’s really when the work kicks in. It was to apply concepts such as intensity. So working hard enough within a session, and then working frequently enough, to make the body feel like it needs to change.
If we want to eat three times a day, perhaps we should be exercising three times a day. And that speaks to this concept of specificity. So specificity of exercise tells us that if we want to get better at something, whatever exercise we’re doing needs to mimic it as best we can.
So it was more of just how to apply the exercises that perhaps we were already using. So it kind of felt like we were using tools in a tool box, but in the wrong way. I always say that if I’m stuck on a desert island, and I have one therapy tool to bring with me, it would be surface electromyography or sEMG. And it’s just a fancy way to say that it’s a little patch of electrodes that we can put over the patient’s skin, tells us if the muscles are activating. They can activate in good ways or bad ways. And then it’s our job to figure out how to activate those muscles in ways that work to help patients exercise. And then we can look at what this tool is showing us on a computer screen, so that the patient and I can look and see was that a harder swallow? If not, you better try harder next time.
Gray: So this is about not just pushing harder, but also using data to quantify what exactly is happening during these exercises.
Burkhead Morgan: Exactly. And now we are using these types of tools like SEMG biofeedback to not only work on strengthening, which was we were kind of strengthening everybody, whether they needed it or not. And now we’re using these tools to work on, maybe not so much strengthening, but speed, precision of movement, coordination, endurance, other things, other than, “Swallow, swallow harder. Maybe we should do it 10 times. Maybe we should do it 15 times.” We now have tools that help us really engage the patient and help us figure out how to do something other than just swallow over and over again, and hope it makes us better.
Gray: That makes sense. Because when I go to the gym it’s not just: “lift,” “lift that higher this time,” “lift it higher again.” You’re also working on balance, flexibility, endurance… many things.
Burkhead Morgan: Precisely. Yeah. And depending on what it is that you want to improve upon. So if you want to get bigger biceps, you’re going to do a bunch of curls. If you want to get better balance, you’re going to do yoga. Two very different types of exercise, but they are in line with your goal of having better balance, lean tone versus bulky tone.
Gray: Could you give an example of a specific dysphagia treatment, or an exercise that you might modify through this lens of exercise science?
Burkhead Morgan: Sure. So in the past, as a young clinician, I only knew to maybe do some effortful swallows. I didn’t know how many, and I didn’t know how often. So now applying the principles of exercise science, I would have a patient hooked up to this SEMG, this biofeedback tool, so that they can see how hard they’re swallowing, and if they need to swallow harder to really engage the muscle to the adequate level they should. And then I would also, depending on whether I was working on endurance or strength, I would make them work for a longer period of time, or a shorter period of time, depending on which of those two parameters I wanted to work on.
And then a third way would be again, if you are at the point that you want to eat three times a day, then I’m going to give you homework. You’re going to come work with me. We’re going to sort out how you should approach this exercise and then you need to do it breakfast, lunch, and dinner time, if that’s really how we want to work on your endurance, so that you can eat three times a day.
Gray: We talk about interdisciplinary approaches to care often, but exercise science is not one that always shows up. So tell me a little bit about what brought you to exercise science.
Burkhead Morgan: It was looking at these colleagues in PT and OT, and also when you’re in a gym with a physical therapist, the other thing that comes to mind is an athletic trainer, they just are the experts. They know how to exercise. I was being told to exercise, and I didn’t know anything about it, so what better thing to do than to go to the experts? So in my doctoral training at University of FBurkhead Morganda. I went and hung out with the exercise physiologists. Of course, with the Gators, they have that great sports program, but they have that great sports program because they also have the science, and the scientists behind how to exercise, and maximize human performance. So I just thought that that made sense that I wanted to maximize human performance with being able to eat.
Burkhead Morgan: It’s not just about eating, it’s about being able to connect. It’s about eating that Thanksgiving dinner. One of my most profound moments as a speech pathologist was working with a patient who had a feeding tube, and a spit cup, couldn’t even swallow his own saliva. And the following Thanksgiving, only a matter of months of us doing therapy together, his daughter called me on my personal cell phone, and was in tears. And she said, “My dad is eating at the Thanksgiving table with everyone, and we’re so happy.” And that’s the kind of human performance that I want to improve. And it might not be running sprints, but it’s connecting with others. It’s enjoying your meals, enjoying the social interaction, the comfort food, the cultural celebrations that we have when we can eat together.
(Music: ES_Forest Pond With Stars – Polar Nights 44100 1)
At the end of our conversation, I asked Lori for resources that SLPs could use to integrate exercise science into their dysphagia treatment plans. She told me there’s no book on the subject yet, but there is some literature. And we’ll link to that on our website. Find this episode’s on our blog at blog dot asha dot org.
Also, Lori suggests asking your PT and OT colleagues how they approach muscles, exercise, and concepts like endurance. She says SLPs should get to know the muscles used during swallowing and find out what makes them unique.
(Music In: ES_Typewriter Song)
Support for ASHA Voices comes from ASHA’s online conference Innovative Methods for Preschool Assessment, Collaboration, and Treatment. From February 19 to March 2, this continuing education opportunity will explore topics and share strategies for improving outcomes. You can earn up to two and a half ASHA CEUs for participating. Learn more at on-dot-asha-dot-org-slash-preschool.
Support for ASHA Voices comes from ASHA Professional Development. Want to showcase your work and contributions to the field of communication sciences and disorders during a poster session? Submit your poster proposal to ASHA’s 2020 Connect Conferences by February 12. Go to ASHA dot org slash events slash connect to find out more.
(Music Fade Out)
Gray: Lori Burkhead Morgan discussed the importance of collecting swallowing data and mentioned specifically using sEMG. But what about folks that live too far away, or who for whatever reason can’t be around an SLP during meal time? How do we get data about them?
Our next guest might have something to say about that. Georgia Malandraki is an SLP and a faculty member at Purdue University. She recently published a research article in Science Advances on a small wearable device that would be able to provide information to SLPs who are working far away from where the swallowing person is located. The tech is currently in clinical trials. Georgia joins us now from Indiana to discuss this tool and its development. Georgia, welcome.
Malandraki: Thank you so much for having me.
Gray: I’ve seen pictures of the device. It’s small and flat. It kind of looks like a mix between a flattened honeycomb and a flyswatter. And it looks like it fits just under the chin. So is this like a Fitbit for the muscles involved in swallowing?
Malandraki: Kind of. Kind of. But unlike a Fitbit actually, you know you described it as a flat type of sensor patch. It’s actually a flexible sensor patch. it’s made of materials that are flexible and stretchable, so that it can adhere very, very well in areas of the body that are especially kind of weirdly designed or shaped or curvilinear, for example, the head and neck area, right?
One of the key new components about this device compared to other types of wireless sEMG sensors that are out there, is that it has been specifically designed with the head and neck area in mind and swallowing rehabilitation in mind. A lot of the sensors that are out there right now, even the wireless sensors, have been primarily produced for the big limb muscles, so they’re not flexible. They’re not stretchable. They’re not meant to really record muscle physiology signals from the head and neck area.
Gray: Roughly speaking, how does it work?
Malandraki: it is like a sticker that basically the clinician will help the patient adhere it to the head and neck area, especially the first time that it is applied. And it sticks. And right now, we do use a gel to make sure that the adherence is perfect, but we’re working on making it more and more adherent through, continuous development of the materials we use. And once it sticks, it’s connected through a small cable with a miniaturized wireless unit that through Bluetooth connection basically transmits the data directly to an app on the phone or on the tablet or on a computer, and the patient can receive real-time feedback. At the same time, the data are transmitted through a cloud service to a clinician who may be located at another location or in the hospital or somewhere else.
Although, as you mentioned, this device was primarily made for telehealth reasons, it can actually be very beneficial within the hospital or within the center or the clinic that somebody is working as well as a real time feedback device for the patient while they’re working with their clinician.
Gray: We mentioned earlier that it would be able to address populations far away from maybe where the SLP is located. We’ve talked about being inside of a single building. But when you were developing this tool, what problem was it that you were targeting?
Malandraki: I was targeting a couple of different problems. Number one, from a researcher’s perspective, a lot of the surface electromyography devices that are very expensive and we have either in research labs or in clinics, as I said priorly, they are primarily designed with sensors that have been made for large muscle groups.
The second motivation that was a very practical and very important motivation was that a lot of times we have patients that come here to our clinic here at Purdue or the prior clinics that I’ve worked at. And they typically can come in and receive their rehabilitative treatment therapy, their exercises for example, two or three times a week. And that’s kind of the maximum that we can accommodate, that the patients can come in. But ideally, in order for exercises for swallowing to be effective, we know now that we have to follow principles of exercise physiology and neuroplasticity, and these principles are telling us that we need high intensity and frequency of these exercises. So ideally, we prescribe them for daily practice, but that means that we end up giving a sheet of paper with a lot of exercises to our patients and say, “Do these at home.” They’re very expensive. We don’t provide them with biofeedback system necessarily at home. And they do them by themselves.
Gray: And those biofeedback systems are often fairly large. Is that correct?
Malandraki: They’re fairly large and very expensive. So the second reason was I ended up having patients that I was sending home with these exercises, and I was kind of like hoping they were doing them correctly. I didn’t have the means to send them home with large biofeedback, expensive devices, not all of them. Maybe I could lend them to some of the patients, but not all of the patients. And so that was number one. I wanted to make sure my patients were able to do these exercises to the maximum potential benefit for them.
And the other motivation was, as you mentioned from the beginning, patients who live in rural areas.
So the motivation was three fold, I guess. Number one, create a better system for data acquisition and analysis and specifically designed for the head and neck. Secondly, for the patients that we already see in treatment, but we can’t see them every day, it’s impossible. And thirdly, for the patients that live in rural areas, so for telehealth applications. So it was compilation of things that led to the development of this technology.
Gray: You mentioned some of the obstacles in getting a biofeedback device in the homes of someone that you wanted to measure their swallowing. Can you talk about some of those obstacles are?
Malandraki: Yes. And this is a very good question. We actually, even before we started developing this technology, we actually interviewed quite a few patients and clinicians across the country. And one thing that kept coming up was that patients- And was coming up from both clinicians and patients, by the way was that they ended up not being adherent to their exercise program. And the reason was, they didn’t have devices available to give to the patients, or the patients didn’t have devices that could actually provide them biofeedback at home or outside of the clinic.
So the main reasons for that is these devices, as we said before, they’re large. They’re rather expensive. And right now, insurance agencies do not reimburse the use of these devices. They reimburse therapy, but they do not reimburse for the device per se.
I would say a third obstacle would also be how easy these devices are to use. Some are really easy to use, so it’s easy for patients to learn how to use them, and some are not that easy. So sending an sEMG device at home and teaching somebody how to place electrodes when you’re not using something like our sensor patch is much more difficult.
I think that it’s great that we have more and more devices. And I think that as the years go by, I feel like there is an understanding that cost and size is an issue, and a lot of people have been working on that, but there’s still I think more that we can do to make sure that these devices are affordable and people can actually use them at home.
Gray: What’s next for the wearable sensor?
Malandraki: So for the wearable sensors, a couple of things. We are continuing the research, and we’re also have started the commercialization path.
And my hope is, because a lot of people ask this question, when the first version is going to be available, and my hope is in about a year or so, that we’ll be able to start selling our first device.
Gray: I understand you’re from Greece.
Gray: Do you go back very often?
Malandraki: I do, yes.
Gray: What I’m wondering is: West Lafayette is pretty far from Athens. When you’re working on telepractice solutions to dysphasia treatment, are you thinking about some of the people in your life that you’re far away from?
Malandraki: Absolutely. Absolutely. That was a big motivation for me. I was always like, “Okay. If somebody in my family ever has dysphasia, where do I even send them in Greece?” That was a big motivation as well to even be involved in the area of telehealth.
Gray: Tell me about that.
Malandraki: Yeah. I mean, thinking about your loved ones always. I think that’s why we wake up every day, thinking about the people that we love most. And being so far away from home, the emotional attachment I think increases even more. So it’s very important for me to feel that if anything ever happened and they needed those services, those services would it be available. And if they’re not available locally, that we would be able to provide them via telehealth. I have been consulting via telehealth, even in patients in Greece and in other areas in the past, and there are ways to do that. There are definitely ways to do that. So I know a lot of people think telepractice and dysphasia is something very challenging. It is very challenging. It is something that has to be done very, very carefully. It is doable, but there’s lots of considerations that you need to take into account.
Gray: Georgia Malandraki, she’s an SLP at Purdue University. Her article on a tool to remotely collect data on swallowing was published in Science Advances in December of 2019. Georgia, thank you.
Malandraki: Thank you.
(Music: ES_Forest Pond With Stars – Polar Nights 44100 1)
Gray: We’ve been talking about dysphagia today on ASHA Voices. We’ve discussed how to measure dysphagia treatment and what types of tools will do that measuring.
But if you work in a school, you might have other questions. When you thought of becoming a school-based SLP, did you picture feeding and swallowing as a part of that work?
While at ASHA Connect last year, I spoke with presenter Emily Homer. Emily is an SLP with over four decades of professional experience, and she’s a consultant who focuses on swallowing and feeding in schools. That’s what we’re going to discuss today.
I began our conversation by asking Homer to identify a few of the common challenges surrounding feeding and swallowing in schools.
Homer: Well, typically you know in the past, swallowing and feeding has not been within the scope of the school district. So, there’s a lot a school districts that do not address swallowing and feeding and are really quite fearful to do that. And, I would say the main barriers that people are facing is fear of due process and things like that because it is a health-related issue. The lack of administrative support to address it in the school setting, and the time. It’s a very complex disorder as well, which requires a real systematic procedure, so that things aren’t missed.
Gray: And I think we’re going to unpack a lot a that in this conversation. But let’s start with the fear. What is it that people are afraid of when it comes to this issue?
Homer: Well, because particularly with swallowing, which is frequently referred to medically as dysphagia, there’s a risk of a child developing aspirate pneumonia. There’s also a fear of a child choking. And when a speech pathologist has the skills but has never used those skills, they’re often afraid to start doing it, and rightly so. So they would have to update their skills. School districts tend to think, well, this isn’t something we’ve done. We don’t know what it is. It sounds medical so we don’t want to do it, you know. And so unfortunately, therapists are put in difficult situations because they know that these issues are in the schools, but their district is saying they don’t want to do it because it’s too risky.
Gray: But you have some kind of concrete tips, some strategies to make this work, right? (Yes)
So, let’s go through a few of those. What can school-based folks do to better serve the people they work with?
Homer: Okay. So, yeah, there are some definite things. And, and it is a process; it takes a while. But first of all, they need to educate their administrators on what swallowing and feeding disorders are, what are the risk factors, and who are the children in the schools that are high risk for this. They need to also inform them of how it can be addressed in the schools. And that’s one of the things I really talk to. Because for the past 23 years, my school district has been addressing it, using a district- approved procedure.
Gray: Which school district is that?
Homer: St. Tammany Parish Schools in Covington, Louisiana. So we started this 23 years ago, when we saw a need for it. And what we have is a step-by-step procedure that has accompanying forms, so that every child that has these concerns really follows this procedure so that there’s no gaps, there’s nothing missed. And what we solved then, is a safe swallowing and feeding plan that then the classroom staff can be trained in, the cafeteria staff can be trained to prepare the modifications of the diet, and there’s a system in place for maintaining safety.
Gray: With this plan, what kind of steps are involved, and what do they look like when they’re enacted?
Homer: The first step is a referral process where the signs and symptoms are identified in the student that is considered to be at risk. The next step is we involve the parents. We talk to the parents. We send home a form that they send us medical history and things like that, and we kind of pull them into the swallowing and feeding team. Then we do a clinical assessment, which we call an interdisciplinary observation, of the child eating in the school cafeteria. We suggest modifications and things, and we really determine how to safely feed a child. Following on that, we have a system for referring for instrumental. There’s a system for cafeteria training for the modifications, and then there’s a systematic way to monitor and consult with teachers so that the child’s plan remains pertinent and appropriate.
But I have to mention that before you get started in this, you really need to have district buy-in. And I think that’s one of the greatest challenges is that speech pathologists have to work with their administration to adopt these things. Because I would never want a speech pathologist, or any other professional, addressing this in the school on their own, independently.
Gray: So I heard you mention earlier, the family needs to be a part of the feeding team. And now you’re talking about the administrators. What I’m hearing you say is that this isn’t something that should fall just on the speech-language pathologist alone.
Homer: No. And because they are the most knowledgeable professional on the school campus about dysphagia and swallowing, they see a need, and they often want to go ahead and take care of it. But it needs to be a team approach. It is a team approach in every setting. It’s in skilled nursing homes. It’s a team approach in hospitals. It needs to be a team approach in school districts as well.
Gray: What do you say to someone working in a school that says… “I want to engage with this, but I have so much paperwork right now. I have a large caseload. I’m already overwhelmed; how can I put this on my plate as well?” What would you say to them?
Homer: You know, and that is such a tricky thing, because I know that they are. Because I’ve been in the school, in the schools for 43 years. And I know that they’re overworked, and I know they have crazy paperwork, and that their schools depend on them. But we don’t have the luxury of saying, “This child has a fluency disorder, but hey, I’m just too busy; I can’t do it.” You know, we don’t have that luxury. We really have to do what we have to do. And what I have found is that, when SLPs start addressing swallowing and feeding in the schools, it is such a unique area for an educator to be working in, that upper administration notices the value. And they appreciate the value. And I have found that we were able to advocate for more positions, we were able to really have a little elevated regard for speech pathology when we started discussing these safety issues, and talking to physicians, and working with OTs and PTs and nurses all together. It really lifted up speech pathologists.
Gray: What’s happening if that’s not being addressed?
Homer: Children are at risk for choking. They’re at risk for aspiration, undernutrition, dehydration. And it’s happening, believe me. It is happening. We have special needs children who are not adequately nourished, who are at risk for choking at school and at home. There are things we can do to have them be safe.
Undernutrition’s an issue, because it takes them so long sometimes to eat that they eat very little in the timeframe that they have. There are things we can do to make ‘em more efficient during their lunch time to eat quicker and easier, not get so fatigued. There’s so much we can do, to help these children.
Gray: Do you have any memories of situations that you’ve came into, and saw a positive change?
Homer: I’ve thought about this and I, you know, there’s no way really to get good research data on the effect of a swallowing and feeding team on a child at school. Because you don’t say okay these children will get it, and these children won’t, so let’s compare and see what happens, okay? (Laugh) You can’t do that. But I suspect that we have really prevented children from going on tube feeding. Because they are able to eat safely and efficiently at school, and it doesn’t escalate into a situation where they’re not able to handle eating. And I think that children are happier at school, because they are well-nourished and hydrated. And they’re able to eat with their peers.
Gray: I would imagine that that benefit shows up in all parts of the school day.
Homer: Across the curriculum. Because if you’re hungry, if you’re undernourished, if you’re dehydrated, you cannot focus. you cannot concentrate on your lessons. And so, is it educationally relevant; absolutely. Because if you are lethargic, if you are absent from school because you’re sick, you’re not accessing your curriculum. You’re missing academics. You’re not able to socialize. You know, so nutrition and hydration… then becomes an educational relevance issue. Because you have to be at school, you have to be healthy in order to participate.
Gray: Homer, thank you for your time.
Homer: Thank you, appreciate it.
Gray: Emily Homer is an SLP and a consultant whose work focuses on how school districts can provide swallowing and feeding services.
One more quick note before we go: ASHA’s School Services team wants to emphasize the important role school based SLPs play in assessing and treating students with feeding and swallowing disorders. And they say administrator buyin and support are a big part of what makes successful treatment possible, as treating students with feeding and swallowing disorders is a team-based effort.
(Music: ES_Forest Pond With Stars – Polar Nights)
ASHA Voices is produced by the American Speech-Language-Hearing Association and comes from the team behind the ASHA Leader magazine.
Support for ASHA Voices comes from ASHA’s online conference, Innovative Methods for Preschool Assessment, Collaboration, and Treatment. In it, you can explore key topics and get strategies for improving outcomes beginning February 19. Learn more at on-dot-asha-dot-org-slash-preschool.
Support for ASHA Voices also comes from ASHA Professional Development. There is still time to submit your poster proposal to ASHA’s 2020 Connect conferences. Get yours in by February 12. Go to ASHA dot org slash events slash connect to find out more.
Production assistance comes from Pamela Lorence. I’m Gray, and this is ASHA Voices.
(Music: ES_Hyperthymesia – Frank Jonsson 44100 1)
Next time on ASHA Voices …
We know if can be difficult to talk about race, but author Ijeoma Oluo reminds us why it’s necessary.
Oluo: When we decide not to have these conversations, what we’re saying is, “I would rather the people impacted by this just continue to carry this burden on their own.”
Gray: Best-selling author Ijeoma Oluo and former ASHA President Elise Davis-McFarland join me for a discussion about race and share concrete examples of actions that can make a big difference in the lives of those around us
That’s next time on ASHA Voices.