Ramblings from ASHA16

Another ASHA convention has come and gone.  ASHA, for me, is a time that I wait all year for those 5 wonderful days of randomly and sometimes it’s intentionally running into friends from all over the US.  It’s a time of vowing every year that I will make it through the entire exhibit hall and never do and will go to X number of courses.  

For many, the planning begins at the beginning of the year.  People write their abstracts, submit them to ASHA and then wait for months to find out if they’re presenting.  After a long wait, emails start flying in, either a congratulations or “we’re sorry to inform you”.  Registration and housing opens in August with the internet flooded with SLPs and audiologists trying to get the best and closest room available.  Then it’s wait again until November.

The first sign of ASHA is always going to the airport, getting on the plane and trying to figure out who will also be attending the convention.  Poster tubes and planners can be found all over as people are excited to present their poster or planning their sessions as they wait.  

I was fortunate to attend several live sessions and poster sessions this year.  

My favorite poster session, by far was by Brenda Arend and Vince Clark on Starting a FEES Program in your Healthcare Setting, The Benefits and Barriers.  They were a popular poster and a wealth of information!  If you are on Facebook and a member of the Dysphagia Therapy Group Professional Edition you can find the information on their poster session here.   If you are not a member of the group and would like to be, send us a request!

My favorite live session this year was the session by Dr Michael Crary, Dr Giselle Carnaby and Lisa LaGorio, Using MDTP (McNeill Dysphagia Therapy Program) to Rehabilitate Severe, Chronic & Treatment-Refractory Dysphagia: A Review of Multiple Complex Cases.  This course was most likely my most tweets at the convention.  Not on Twitter?  I’ll share them here.  

I took the MDTP course 4 years ago!  I can’t believe it’s been that long!!  You can find my post here.

Sometimes we do the different assessments but then treat each patient the same.

The exercise is actually swallowing.

Promotes continuity of care with specific timelines and advancement, regression.

Frequency and intensity are high while burden on the patient is low.

MASA, FOIS, VAS (Visual Analog Scale), weight, improved swallow efficiency to assess.

Physiology-Fluoroscopy, increased lingual-palatal pressure, hyolaryngeal excursion, pharyngeal contraction, more efficient swallow.

5 articles available on

 
No treatment should ever work for everyone.
 
Patient with history 5 years 6 months dysphagia. PEG and NPO. Dysarthria, lingual weakness, weak cough.
 
Case 1 aspiration with all consistencies.
 

Case 1 15 day program. Progress is not lineal. There is a model learning component to

130 to 150 swallows per session.

Accuracy is 8 out of 10 successful swallows.

Focus on enhancing the motor planning for patients when necessary.

Case 1 post Botox and still aspiration but also some swallows.

Success is not always “no aspiration”.

Can push diet and advancement with cognitive and motor planning treatment.

Severe motor planning deficits may take longer to rehabilitate.

Patient may needs to unlearn faulty behavior.

Ice chips are the beginning of the protocol.

Unexplained weight loss can be our nemesis in therapy.

Sometimes a FOIS level 5 may be functional for a patient.

Some patients are ok being a functional aspirator.

can be completed in acute care, rehab, outpatient. You may just need to start at ice chips and advance as cognition improves.

may be a replacement for traditional exercises in appropriate patients.

is working to put everything together for the patient.

The program is to challenge the system and wake it up.

Once initial fears subside in patient there was rapid progress.

A well performed careful assessment is everything.

Psycho social issues can reduce movement/swallow progress.

Mia information and lack of systematic progress can reduce progress.

Careful systematic therapy can succeed by supporting self practice.

A lot of techniques we have learned don’t always work.

 

Patients are not static. Sometimes patients “treat” themselves or don’t follow our recommendations.

New study, was superior to traditional therapy and to and NMES combined.

Here is MDTP in a nutshell or a series of Tweets.

Another great session was by a group of experts in the field, Joe Murray, Debra Suiter, Pam Smith and Jaqueline Hind titled The Practicing Dysphagia Clinician: What Are We Afraid of?

There was a lot of great conversation with this talk as they presented a case and allowed for audience participation and discussion.  One of the comments that brought about a lot of conversation was the topic of the diet waiver.  What do you think of the waiver and do you use them in your facility?  How do you feel we can better “cover our butts”?  

I still can’t believe the convention is over and I will have to wait another whole year to see my friends and speech family!!   

 

 

 

 

 

 

 

ASHA 2016

Where did the time go?   I can’t even believe that next week is the ASHA convention!  After a long week it is time to start packing because if you’re like me packing early is a must!!!

Now it’s time to make my packing list!  

Comfy clothes (I’m not presenting and have no intention of dressing up! Long sessions and much learning calls for comfort!)
Comfy shoes (There’s A LOT of walking!)

Light bag (To carry my iPad and chargers. Nothing heavy because it is a long day and did I mention a lot of walking?)

Hygiene supplies (Shampoo, soap, the works. Don’t forget the deodorant…..long days, miles of walking!!)

Sweater or light jacket (Some rooms are hot and some rooms are cold.)

My list of sessions. (There is nothing worse than arriving at the conference and having no clue where to go. There are computers to create and print your agenda, however they can be very crowded.). I also try to double-book sessions in case one might be full or let’s face it, I just might change my mind.

Portable charger (I use a New Trent which will charge my phone and iPad fully at least once if not more.  I always go for a charger with a high mA output.)

Power strip or multi USB charger. (Let’s face it, hotels often don’t have enough outlets for all your electronics and if you have a roommate or 3, you will definitely need the extra charging space.  

A small first-aid kit. (You never know when a headache will come on or you need a band aid for blisters from SO MUCH walking!)

An open mind. (There are so many sessions to attend and so much information to learn!! Be ready to learn, not only in your sessions but in the exhibit hall.)

Pajamas (There is very little time to sleep, however it’s nice to be comfy during those brief periods of rest.)

Be prepared to learn, have fun, meet new friends, visit with old friends and enjoy the atmosphere!
Follow @dysphagiarmblng for live tweeting of ASHA 16 dysphagia sessions!

5 Considerations for Continuing Education

If you are like me, you are inundated with social media advertisements for various certification or continuing education courses.

The question is…..which do you choose?

We most certainly can’t afford to attend every course or obtain every certification.  So how do we figure out which courses are worth our time and money?

  1.  The course is ASHA approved for CEUs-Be aware.  Just because the course provides you with ASHA CEUs doesn’t necessarily mean that it is a good course.  While courses are required to be peer-reviewed for ASHA, that doesn’t mean the course is the cream of the crop.  ASHA also does not endorse any specific treatment or tools.  We still have to be conscientious learners.
  2. The course offers “fast” results-I have had the very few patients that met their goals in a short amount of time.   When we work with patients with dysphagia, we are typically working on changing muscles.  This involves strength, coordination and timing.  I can’t go to the gym and strengthen my arms in “just a few sessions”.
  3. Watch the evidence base-A new course can have 150 different references to “support” it’s use.  Read the evidence.  Some may not even be related to the technique you are learning.
  4. Does it really make sense?-The presenter may have you convinced by the end of a course or even through the advertisement that this new technique works wonders because of x, y, z.  Sit down and think about this.  (This is where our critical thinking caps must be ready to go!)  Does this technique make sense?  If I have a patient concentrate on working their knee, is that really going to change the swallowing system?
  5. Use your social media-Post in Facebook groups, use Twitter, Pinterest or even the ASHA SIG groups to question new courses and techniques.  You shouldn’t have to shell out thousands of dollars on a technique that doesn’t work.  You can absolutely keep an open mind to new techniques but maybe others in these forums can help you problem-solve why these techniques may or may not work.

We all work hard for our money and time is a precious commodity.  Choose continuing education and new techniques with care and always hold the welfare of your patients paramount.

What are some courses you have really enjoyed or wish you would have skipped?

What do you think would be the best resource to use to share and look up quality, evidence-based continuing education courses?

Quick Pocket Reference for Tracheostomy Tubes and Speaking Valves

I would first like to thank Northern Speech Services for sending me this wonderful reference to review!

If you haven’t yet had a chance to take a look at the new Pocket Reference from Northern Speech Services, you should!  This is a great reference tool for working with patients with trachs.
First, the guide is not much bigger than my iPhone 6.  It very easily fits in my scrub top pocket.  The pictures are large and very visually appealing.  Each page consists of some text but is not too much to read.  It is truly a reference tool.

The book consists of the following sections:  Basic Tube Anatomy, Selection, Cuffs, Brand Identification, Code on Neck Plate, Sizes, Speech, Talking Trach Tubes, Speaking Valve Identification.  Each section consists of pictures and texts to aid in the identification and decision making for Trach tubes and speaking valves.  

Whether a seasoned or new clinician working with patients with trachs, this is definitely a guide worth the money!

Find the Quick Pocket Reference for Tracheostomy Tubes and Speaking Valves here.  

The Cost of Thickened Liquids

FullSizeRender

 

Thickened liquids have had a lot of publicity lately in social media.  They’ve been a large part of dysphagia management.  Sometimes, it can be argued that the use of thickened liquids occurs more frequently than other compensation or management techniques.

  • “Texture modification has become one of the most common forms of intervention for dysphagia and is widely considered important for promoting safe and efficient swallowing.”  (Steele and Miller 2010)

Often, products or research is aimed at reducing the use or need of thickening liquids.  The Provale cup is one such product that only allows the patient 5-10 ml per drink, which may or may not be a safer amount of thin or nectar thick liquids.

There is a lot to look at when looking into thickened liquids.  The physical cost is definitely an issue.  Thickener is not cheap.  My friend Vince Clark calculated the cost of pre-thickened liquids and posted the following on Facebook:

When we look at the cost of Thickened liquids:

  • Per Day: 9 x .34 = $3.06
  • Week: $21.42
  • Month: $85.68
  • Year: $1116.90

These are the costs of a single organization.   An individual purchasing thickener may pay double.

We also need to look at how thick we’re recommending for our patients.  Many times and research back that maybe nectar thick is enough.   Dr. Leder looked at patients that aspirated thin liquids and found that these same patients had 100% successful swallows with both nectar and honey thick liquids indicating that nectar thick may be adequate to promote safe swallowing.  (Leder et al 2012)

There has been research leading to the fact that maybe we shouldn’t thicken liquids.  Dr. Logemann et al found honey thick liquids were the most effective in eliminating aspiration when compared to nectar thick liquids and a chin tuck.However, when aspirated, honey thick liquids had the most significant impact causing pneumonia, longer hospital stays or death.  (Protocol 201).

There are times patients are seen for a Modified Barium Swallow Study (MBSS), they penetrate with both thin and nectar so they are placed on honey thick liquids.  Perhaps the debate should not be an all or nothing, thickened liquids or no thickened liquids, but look at the whole patient and make the decision with them.  Always consider those patients that aspirate thin liquids during the MBSS, return home, continue to drink thin liquids and never die from aspiration pneumonia like we sometimes teach them will happen when they aspirate.

My interpretation of this research into my very real daily job is that I need to consider the whole patient and that some patients just need those thickened liquids.  They’re not going anywhere anytime soon.

In fact, thickened liquids can be great therapeutically.  Dr. Bonnie Martin-Harris has done quite a bit of research while developing the Modified Barium Swallow Impairment Profile (MBSImP) and has found that using a nectar consistency during the Modified Barium Swallow Study (MBSS) there is more significant pharyngeal movement during the swallow.  There are also studies looking at how adding “weight” to the bolus can be an effective therapeutic strategy.

We need to be careful in interpretation of research.  Just because an article came out that says not to use thickened liquids at all, don’t go and throw out all your thickener.  (Wallace, this article, 2016).

The cost is not only monetary, but also in our patient’s health, satisfaction and quality of life.  We all have or have had that patient that just really doesn’t mind thickened liquids.  They drink the liquids, they may not be turning cartwheels with thickened liquids but they tolerate them.  Some patients know it’s short-term and once they rehabilitate their swallowing function they may be able to resume thins.

We also have or have had those patients that just outright refuse thickened liquids.  They don’t like the texture or the consistency.  This may be the patient that says, “I know I need them but they taste like snot.”  (A former patient on thickened liquids circa 2011.)  This may also be the patient that refuses to follow your recommendations or just stops drinking all-together.

There always has to be a balance and a consideration for hydration, overall health, respiratory health and patient satisfaction.  I’m not talking the survey the patient gets and rates you on a scale from 1-whatever.  I’m talking about their everyday, I’m happy with my life satisfaction.

Always look at your patient as a whole.  Look at their respiratory system, their overall health, history, cognition and if able create a plan with that patient.

I have completed many MBSS’s with many patients over my years.  “Remember, the person is here because they have been having difficulty with their swallow.  I’m guessing this isn’t the first or last time they have or will aspirate.”  (Wallace at every MBSS when the radiologist is ready to quit because the patient aspirated.)

Remember those elders at the SNF that are put on thickened liquids and remain on honey thick liquids for the rest of their days.  These may be the same people you say wandering the halls, stealing drinks at the water cooler, stealing drinks from the tables in the dining room or sneaking drinks from the bathroom sink.

Steele, C. M., & Miller, A. J. (2010). Sensory input pathways and mechanisms in swallowing: a review. Dysphagia, 25(4), 323-333.

Robbins, J., Hind, J., & Logemann, J. (2004). An ongoing randomized clinical trial in dysphagia. Journal of communication disorders, 37(5), 425-435.

Leder, S. B., Judson, B. L., Sliwinski, E., & Madson, L. (2013). Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: nectar is enough. Dysphagia, 28(1), 58-62.

Dysphagia Awareness

Dysphagia

June is Dysphagia Awareness Month.  A month dedicated to a disorder that most have never heard of but comprises 80% of my work.  It’s not even in my title, so what the heck is dysphagia?

What is Dysphagia?

If you Google dysphagia, you get this:

dys·pha·gia
ˌdisˈfāj(ē)ə/
noun

MEDICINE
  1. difficulty or discomfort in swallowing, as a symptom of disease.
    “progressive dysphagia”

What does a Speech Language Pathologist (SLP) do?

I have worked in a number of different settings as a full-time employee, part-time employee and PRN (as needed).  I have worked in Skilled Nursing Facilities (SNF otherwise known as a nursing home), home health, outpatient (where people come to see me), schools and in the hospital.   Some people research the swallowing process, techniques we use and interventions while teaching people to become and SLP at the college level.

Now, you need to get your head out of the gutter!  When I say I’m working with swallowing, I’m talking about the ability to swallow, saliva, food, drink and pills.  You know, that thing that we do 600-1200 times per day without a second thought!  It’s after a person or a loved one actually starts having a problem that people realize swallowing can “go wrong.”

I have worked with patients with such a variety of diseases.  Thyroid issues, CVA (stroke), Parkinson’s, ALS, MS, Rhett Syndrome, Mitochrondial Myopathy, Shaken Baby Syndrome, dementia, just to name a few.

Typical Day?

So what does a typical day look like for me?  Well, there is no typical day.  I never know what I’m walking into!  In the SNF setting, I walk in the door and hope for the best!  I work with Occupational and Physical Therapy to provide the best care for each elder that I possibly can.  For some that involves working on their cognition (memory, problem solving, executive functions), some work on their speech because they may have difficulty with word-finding (aphasia) but most have some type of swallowing problem.

In the hospital is where my day varies the most.  At the hospital is where I also get to work in x-ray to actually see how the swallow is affected.   I get the chance to mix barium with food and watch, using fluoroscopy, a live feed of the swallow.  Barium is used because it is dense and shows up as a dark substance on the swallow study (Modified Barium Swallow Study or MBSS).  I watch to make sure the muscles do what they’re supposed to do (close the airway, squeeze the pharynx, block off the nose, move the food/drink (bolus) back in the mouth and open the esophagus) and that the food/drink goes where it’s supposed to go, into the esophagus and not into the airway (aspiration) or remains in the pharynx/throat (residue).  I also am called in to assess patients in their rooms and determine the safest diet consistency for them.

Is Swallowing a Problem for You?

Most of the time, I’m told “I don’t need speech, I can talk just fine.” Sometimes, I’m told “I don’t have any problems with my swallowing” as the person takes a drink of water and coughs relentlessly.  I’ve also been told that “It’s just sugar that gets me” as the person drinks water and coughs relentlessly.  If you haven’t figured it out, that relentless coughing often clues me in that the person may be having difficulty with swallowing and that water may actually be going down into their lungs.  So what are some signs of swallowing problems?  Well, here’s a list that may indicate a problem:

  • Coughing/choking with food or liquid.
  • Feeling that food is “stuck” in the throat.
  • Difficulty chewing, losing the food/drink from the front of the mouth (through the lips) or not able to move the food to the back of the mouth to swallow.
  • Avoidance of certain foods.
  • Feeling that food “balls up” in the mouth as the person chews.
  • Frequent pneumonia.
  • Weight loss.

These are just a few things that may indicate dysphagia.  If you or a loved one experiences any of these, go to your doctor who can then refer you for Speech Language Pathology (Swallowing) services.

Rehabilitation

So now, you may wonder what a Speech Language Pathologist (SLP) can do for you.  A Speech Language Pathologist will determine the cause of the dysphagia or swallowing problem and create a treatment plan to rehabilitate the swallow.  Swallowing is mediated by 55 muscles and cranial nerves.  These muscles can be exercised to improve their function.  Now, we can’t necessarily set you up on a treadmill or a weight machine and let you go to town, sometimes these exercises are a little creative and may seem a little silly at first, but your SLP should describe the exercises to you and explain why each exercise is needed.

Sometimes, the SLP will recommend a different consistency of food for you to eat.  It may be recommended that you eat a mechanical soft diet with your meat ground (no crunchy, hard foods) or you may be advised to eat only pureed foods (mashed potato consistency).  It may be recommended that your liquids be thickened using a commercially available thickening agent.  You may be advised to use a compensatory strategy to increase the safety of your swallow such as turning your head to one side or the other or looking down at your lap as you swallow.  Some people have a better swallow if they eat a bite of lemon ice before their food or if they take a drink of water after each bite of food.  Some people even have difficulty with pills and need help in how they take their pills.

Why an SLP?

You may wonder, what makes me, an SLP, the person to help you or your loved one because all of this sounds extremely complicated!  It is very complicated!!  There is no cookbook approach to swallowing disorders and each person has to be treated and evaluated individually.  The SLP holds a Master’s degree.  Why yes, that may mean SIX years of college.  I’m also responsible, after all that school to continue my education through courses taught be other SLPs or professionals.  This is called Continuing Education.  I am required by the state of Indiana to have at least 36 hours of continuing education every 2 years.  I go well above and beyond that because there is always so much to learn!!  I also read research about swallowing.  A lot of research.

Some of us even go a bit beyond that and obtain Board Certified Specialty in Swallowing and Swallowing Disorders (BCS-S).  The SLP will then sign all their paperwork with that BCS-S to demonstrate this specialty.  Holding the BCS-S means that I have participated in 72 hours or more of continuing education specifically in the area of dysphagia, I have demonstrated competency through a test in dysphagia and have demonstrated more advanced work such as educating the public in the area of dysphagia.

My “Job”

My job is not a fleeting/passing moment with people.  I work with people in a variety of settings with something that is very important to them.  Eating/drinking is our staple for social interactions.  We often go out for drinks or go out to eat.  The most rewarding part of my job is when my patient reaches their goal and eats/drinks that item that they have been longing for, but was not deemed safe for them.  It is that time that the patient no longer experiences discomfort or difficulty with one of life’s main functions.  We need nutrition, right?  I work closely with these patients and we develop a connection.  It’s absolutely the best part of my job!  I don’t aim for perfection with my patients, I aim for functional!

Some other cool things about my job?  I get to write this blog!!  I love writing my thoughts out and sharing them with the world.  I never in a million years dreamed that people would actually read what I write!  I have collaborated with other professionals and app developers to create apps for Apple regarding dysphagia.  I have had the opportunity to teach webinars and to travel and teach classes about dysphagia.

National Dysphagia Awareness Month

Our field has, in recent years, lost 2 people integral to the world of dysphagia.  Dr. Jeri Logemann passed away on June 19, 2014.  She was the mother of the field of dysphagia.  I owe her so much for delving into this world of swallowing, assessing and treating that I love so much!  Dr. Steven Leder recently passed away.  He was a major researcher in our profession who brought passion to our field and made us all use our brains!  We will forever be grateful for the work that both of these influential souls have given us and leave to us!

Let’s “celebrate” National Dysphagia Month by spreading awareness!   May all your swallows be functional swallows!

Better Hearing, Speech (and Swallowing) Month

BSHSM

(I love this picture from Simply Thick!)

Often, I am asked what I do for a living.  If I say Speech Pathologist I get that look of “what?”  If I say I work in a school, it’s assumed that I’m a teacher and if I say I work in a hospital, it’s assumed that I’m a nurse.  When I say I work in both setting, there’s mass confusion.

This month kicks off Better Hearing and Speech Month for Speech Language Pathologists (SLPs).   If you’re not sure what an SLP does, well, we do A LOT!  If you are looking for a job with a great deal of variety, plenty of learning opportunities and flexibility, well, this is a pretty good start.  **Disclaimer:  This post is information an SLP will already know and was intended for a variety of readers.**

An SLP can work with people from newborn to elderly.  We work with people that were born with cerebral palsy, developmental delays, autism, Down Syndrome (along with a number of other syndromes) and with acquired speech, language and swallowing problems due to stroke, Parkinson’s, brain injury, cancer, and a variety of other diseases or traumas.

We work with articulation (production of speech sounds), language, voice, cognition (memory, problem solving, attention), reading, social language, executive functioning, motor speech and swallowing.

An SLP goes to school for 6 years, as a Masters Degree is required.  Many SLPs go on to get a Doctorate.  SLPs work in school systems, nursing homes, rehab facilities, home health, First Steps, hospitals, NICU and universities as well as private clinics.  Some SLPs will even go on to research certain areas such as swallowing to help SLPs better understand the physiology, anatomy, assessment and treatment techniques.

Swallowing and Swallowing Disorders is my area of expertise.  I even took the extra step(s) to obtain my Board Certification in Swallowing and Swallowing Disorders (BCS-S).   During the process I had to demonstrate that I not only understand swallowing and swallowing disorders, but also go above and beyond to educate others.

Dysphagia (swallowing disorder) seems to be an area in our field that has very little understanding and even less recognition.  Dysphagia is becoming one of the primary assessment and treatment diagnoses in the medical field.  Some schools even offer dysphagia therapy for school-aged students.

You may wonder what an SLP can possibly do with a swallowing problem.  The SLP is the person that assesses the swallowing difficulty.  Assessment may be completed through (most commonly) a clinical evaluation, Modified Barium Swallow Study (MBSS or also known as a Videofluorographic Swallow Study VFSS) and/or Flexible Endoscopic Evaluation of Swallowing (FEES).

Treatment may happen in the form of diet consistency alterations, compensatory strategies or rehabilitative exercise.

I often ask myself, “What am I doing for my profession?  How am I helping?’  Part of my job has been education.  I have developed webinars and taught live seminars to help further the knowledge of others through evidence-based practice.  I keep current in evidence and continuing education.  I use this blog for education, not only for clinicians but also for the general public.  I use Facebook groups and Twitter to share information.  I have authored/co-authored 3 apps with Tactus Therapy and SmartyEars.

What do you plan to do to share knowledge regarding our wonderful field??

Educating others is a huge part of what we need to be doing.  Let everyone know what we do and why we do it!!