Research vs. Clinical skills

One thing that has become completely apparent through social media is that there seems to be a great divide amongst researchers and clinicians.  

There are the people that swear if one more person asks them to present the article providing the research to the technique they are recommending……….

The truth is we live in a world of Evidence-Based Practice (EBP).  Somewhere along the line, EBP became peer-reviewed research articles published in a relevant journal.  

ASHA defines EBP as:  

Evidence-Based Practice (EBP)

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. Conceptually, the trilateral principles forming the bases for EBP can be represented through a simple figure: Read more about EBP.

EBP_Logo

We do need published research to support what we do.  The trouble is, techniques we try using our general knowledge and clinical expertise may be something we try during a session.  It may be something that comes to us as we sit and work with a patient or client, however we really don’t have the time to sit and wait for the research to be funded, proposed, completed, peer reviewed and published.

Listening to our patients can be very revealing in what works and doesn’t work for them.  Not sitting and listening to the patient and saying, “Well, the research said this would work.”  It may not work for the particular patient.

Honing in on our clinical skills is pertinent to our profession.  You may read an article and think, that might work for my patient if I change x, y, and or z factor.  

Research is a part of EBP.  The studies are great to have and the studies definitely support what we do as a Speech Language Pathologist (SLP).  I, personally, deeply admire those that complete research in our field.

One obstacle I find with research is that I can’t always exactly replicate a study.  Does that mean, if I use a substitution that I’m not following the peer-reviewed published research?

We need to let research guide us in our decision-making skills when assessing and formulating that ever-evolving treatment plan for a patient.  

We also need to use our hard-earned clinical skills that we all worked so hard to earn!

Pudding and a Straw

                                                                                

Picture from: http://www.busymomboutique.com

Haven’t you always wanted a very simple exercise that will work and strengthen the entire swallowing mechanism using resistance?  I do as well.  I have an exercise that I use all the time with my patients.  I am usually chastised by my co-workers when having patients use this exercise.  Patients give me a strange look until they try it.

This exercise has no fancy name.  I call it……..Pudding with a Straw.  It is exactly as the name implies.  The patient drinks pudding through a straw.

So first, let’s look at the evidence…….  I take into account that, from reading research…..I know using a straw increases labial activation.  A thicker, heavier bolus can add resistance to the swallow and can actually increase the movements both orally and pharyngeally with the swallow.   Using an effortful swallow increases sensory input to the swallowing mechanism.  Swallowing is a sub maximal event as a whole, but when the patient focuses and purposefully uses a more effortful swallow, there is an increase in the muscle contraction of the entire swallowing mechanism.

I take all of this into account and then try the method myself, to see what I feel.  When I drink pudding through a straw, not a Panera smoothie straw, not a regular drinking straw, a cocktail straw/coffee stirrer size straw, I can feel a difference.  My lips purse together with increased effort.  My tongue retracts and tightens, my jaw tightens.  I then suck enough pudding through the straw to swallow and use an effortful swallow.  At one time, I have incorporated straw use with a safe consistency bolus for most, an effortful swallow and a weighted bolus.  I have also used the entire swallowing structure.

I believe it is important and necessary that we look at the swallowing mechanism as a whole, a process, rather than 4 parts.  It’s great to break the swallowing system down into phases for descriptive purposes, but every part of the swallow is connected in some manner and every part of the swallow deserves some attention.

Now, keep in mind, not every patient can start at the level of a small cocktail straw/coffee stirrer or even the pudding.  I can modify the straw by either using a larger diameter straw (Panera smoothie straws seem to be the largest I’ve found at this point).  Regular drinking straws also work very well.  Not only can I change the diameter of the straw, I can change the size of the straw by cutting it in half or in thirds.  The shorter the straw, the easier the task.

Now, keep in mind, the viscosity of pudding can be varied as well.  Many times I will use a thickened liquid or applesauce for patients that are not able to start with pudding.  I may work up to yogurt, without the fruit.  Then with the pudding, in my experience, I have found that sugar-free pudding seems to be the thinnest, followed by home-made, then Snack Pack pudding.  Snack Pudding, the chocolate seems to be the lesser viscous, followed by butterscotch, with vanilla having the thickest viscosity.  Room temperature vs. refrigerated also makes a difference.  Room temperature pudding is a little less tedious for the patients, while with the refrigerated, I’m also adding the temperature aspect to my sensory portion of therapy, in addition to the difficulty of the task.

I don’t write a goal for the patient sucking pudding through a straw.  We may be working on lingual strengthening, pharyngeal strengthening, tongue base retraction, labial seal.  I don’t write my notes as “the patient was able to drink a Snack Pack cup of refrigerated chocolate pudding.”  We were working on using an effortful swallow, straw sucking for increased labial seal, weighted bolus for resistance.

Now I do time my patients and keep track of the time.  I will time the patient to see how long it takes to complete the task.  As the patient gains strength with the task, the time should decrease.  You can also use e-stim or sEMG with your patient as they are completing the task.

I don’t stress if the patient needs the entire session time to complete the task.  This is what I want them to do!!  I want the patient to use an effortful swallow.  I want to apply the rules of neuroplasticity and use a specific swallowing task, applying resistance and specificity.  My patient is swallowing, using both an effortful swallow with a focus of tongue to palate contact and using a weighted bolus with the thick pudding.

I challenge you to try this exercise.  Try the vanilla with the coffee stirrer/cocktail straws and feel what the exercise does for you!

Clark, H.M. (2005).  Therapeutic exercise in dysphagia management: Philosophies, practices and challenges.  Perspectives in Swallowing and Swallowing Disorders, 24-27.

 

Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.

 

Burkhead L.M., Sapienza C.M., Rosenbek J.C.  (2007).  Strength-training exercise in dysphagia rehabilitation:  Principles, procedures and directions for future research.  Dysphagia; 22:  251-265.

 

Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial.

 

Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.

 

Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.

 

Wheeler-Hegland, K.M., Rosenbek, J.C., Sapienza, C.M.  (2008). Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  Journal of Speech, Language and Hearing Research, 51, 1072-1087.

 

Burkhead LM.  Applications of Exercise Science in Dysphagia Rehabilitation.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia) June 2009; 18: 43-48.

 

Park JW, Kim Y, Oh JC, Lee HJ.  Effortful Swallow Training combined with Electrical Stimulation in Post Stroke Dysphagia:  A Randomized Controlled Study.  Dypshagia (2012).  DOI: 10.1007/S00455-012-9403-3.

 

Bulow M, Olsson R, Ekbert O.  Videomanometric Analysis of Supraglottic Swallow, Effortful and Non Effortful Swallow and Chin Tuck in Healthy Volunteers.  Dysphagia.  (1999); 14(2):  67-72.  DOI: 10.1007/PL00009589.