What in the World?

I haven’t been on here in a while.

 Why?  You might ask……

Well, things have been rough at work.  My caseload continually started dropping, but I thought it was not too big of a deal because, after all, I was the Rehab Director and I had those director-type things I needed to do.  Make sure documentation is completed and accurate, checking daily for G-codes, reviewing every chart prior to submission to medical records, daily meetings, keeping all staff up to date on what was new with our company.

Unfortunately, the hospital didn’t see my value in that area and decided that I had a month to increase my caseload (yup, that included marketing my own services) or elimination of my position.

Our company, who contracts us to the hospital, decided that the best option was to have me start covering a local nursing home as well.

I’ve worked at that nursing home in the past and swore I would never go back.

Fortunately, a friend of mine has connections with a contract traveling company.  One day I’m emailing a recruiter, the next day, we’re talking on the phone.  By the end of the week, I had a phone interview with a school.  Yup, you heard me, a school system.  By the next week, I had a full-time job offer, guaranteed 40 hours/week, willing to work with my travel/speaking schedule and mine to start the following week.  I had the difficult job of talking to my supervisor and going part-time at the hospital, so that I could work full-time at the school.

Basically, my outpatient caseload now is 3 and the nursing home has less than 3.  My outpatient caseload equals 4 hours a week.  I think I made the right decision.

The bad thing was that in order to not give notice, I had to work at the school, cover the nursing home and the hospital for 2 weeks.  That doesn’t sound bad, but I do think I’m still recovering from working so much.

What will I miss most about my hospital job, other than the 3 outpatients I’m keeping on…………..

1.  Modified Barium Swallow Studies.  I love modifieds.  I love diagnosing dysphagia and working on that treatment plan to improve my patient’s swallowing ability.

 2.  Outpatients.  I love working with adults.  I love working with them and helping to improve aspects of their lives.  I also love that moment, when they’ve attained their goals and the gratitude they show.

 What will I NOT miss……….

 1.  Productivity.  That’s right.  I’m not a factory.  Some patients take longer than others.  Sometimes, outpatients need 2 hours, most times an hour will do.  45 minutes is not sufficient even though that’s the magic number from a business stand point.

 2.  Swallowing evaluations for EVERY patient diagnosed with CVA, whether it’s actually a CVA or not.  Sometimes they get it right.  I’d say it’s been about 20% correct diagnosis since we became a stroke certified hospital.  Not that I don’t love evaluations and swallowing evaluations.  When I know it’s not a stroke going in, the patient has passed the 3 ounce water swallow screen multiple times and nursing reports no difficulty with meals or pills, it seems like an enormous waste of tax payers money and my time.

 3.  I took the job as rehab director because I wanted to learn to be a manager.  I really wanted to get into the managerial aspect of therapy.  I did NOT want a title, expectation to maintain the same productivity, however take the blame when I didn’t have time to do something.  Also, I’m not into marketing.  It’s not what I do or what I went to school to do.

So yes, I work in the school system now.  I’m adjusting.  I like the kids.  I have yet to like the artic, but I was really excited the other day when a first grader who substituted k/t and g/d actually started using t and d in words.  It’s the little victories.

Will I quit dysphagia therapy or will my passion for it waiver.  Never.   I will continue to read research on dysphagia.  I will continue to speak on the topic of dysphagia.  I know that I will soon get back into the practice of treating dysphagia full time.

Just for now, I need a change in pace in my work setting and boy did I ever find that!

 

Cranial Nerves: App Review

App:  Cranial Nerves:  Pocket Clinical Resource

Price:  $2.99

What it is:  An incredibly simple app to use to learn and look up information on cranial nerves.

System:  iOS (iPhone and iPad)

Version:  1.2.4

Let me start off by saying:  I LOVE THIS APP!

I was referenced to a cranial nerve app which was $60.  I thought to myself there has to be a less expensive version that I can utilize just as easily.

I found the app!

We’re told often to complete a cranial nerve assessment, especially looking at neuro patients including CVA and patients with dysphagia.

Cranial nerves can be daunting and scary.  They don’t have to be!

Along the left side of your iPad (for that version of the app), you have a list of the nerves by roman numeral.  Touch the roman numeral corresponding to the cranial nerve you are trying to find.

You will find a full description of that nerve:  function, nerve tract, integrity tests, symptoms and signs and images.

Yes!  This app will tell you how to test the nerve and symptoms signs if the nerve is not intact.

Sometimes there just is not enough information.  If you are a Google/Wikipedia fan like me, then this app was designed for you.  You might notice at the top of the description of the nerve in the above picture, there is a box icon, a G icon, a globe icon and a picture icon.  If you have internet access, touch the G icon.  Amazingly you will be directed to a Google search of that nerve.  Similarly, touch the globe icon (third from the left) and you will be directed to a Wikipedia search of that nerve.

This app can be used as a learning tool and a quick reference when you just can’t remember what that nerve is for or how to test it!

This is a 5-star app in my book!

G-Codes and Insurance and Rehab Optima…….Oh My!

I work in a critical access hospital.  I see patients in acute care, outpatients and do all MBSS in our facility.

 I am also the Rehab Director of our deparment.

 Our regional manager implemented G-Codes in our facility in early January.  We have been in-serviced on G-Codes and using them in our documentation.

 What are G-Codes?

 These are required codes when working with Medicare Part B patients.  There are 7 codes from which SLPs can choose to use with their patients.  These areas define the most relevant area with which we are working with our patient and must include an impairment modifier for each.

 ASHA offers information on G-Codes and has created a wonderful list of all the codes and modifiers here.  ASHA also recommends using ASHA NOMS which directly correlate with the impairment modifiers.

 The bottom line…..if you don’t use the G-Codes and Modifiers, you won’t get paid.  You can only use one code at a time although you can treat multiple impairments at one time.  (i.e., you may code for swallowing, however treat both dysphagia and expressive communication).

 ASHA offers an on-demand webinar explaining G-Codes for $99 for ASHA members and $129 for non-members.  The Specialty Board on Swallowing and Swallowing Disorders also offers a webinar by Nancy Swigert for $25.00.

 Insurance

 I don’t know how it is in other states, but here in Indiana, insurance has been a major roadblock for therapy.

 Medicaid often severely limits our sessions.  They will often give us 12 or 24 sessions.  When you have a patient that just had a stroke and is severely aphasic, 12 sessions at 2 times a week, 12 sessions at 1 time a week followed by a home program, typically does not cut it.  This is what we are allowed.

 Even if that patient has Medicare as a primary.  The Medicare is unlimited.  We are not under caps being a Critical Access Hospital.  Medicaid as a secondary limits the sessions because the patient cannot afford to pay the 20% out of pocket.

 BCBS typically gives us 20 sessions if they are primary, 60 sessions if they are secondary.  They will not pay for a cognitive therapy code if CVA is the primary medical diagnosis.  There is a list of diagnoses, small I might add, that I can use with specific codes for reimbursement.

 If you live in Indiana and have a stroke with BCBS as your insurance…..please don’t have cognitive issues only requiring cognitive therapy.  They won’t pay for that.

 I dread to see all the upcoming changes in therapy approvals for insurance with all the healthcare reform coming.  It has definitely changed to this point.

 Rehab Optima

 Our company primarily staffs nursing homes.  We have an acute care hospital contract for a critical access hospital.

 Our company recently switched from Casamba Smart to Rehab Optima.

 WOW

 Smart wasn’t necessarily functional for us, but RO is definitely not.  We have had nothing but issues since we started!!

 Hopefully it gets better!

Dysphagia Assessment

So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely seen people do a thorough dysphagia bedside evaluation.

 I’m trying to standardize the manner in which I complete my bedside evaluation. I have started using the SOPE, the MASA and the Sage during every assessment, along with a thorough chart review and assessing aspiration risk factors. I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The Sage assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia from my standpoint. I also do the traditional feel for laryngeal elevation, but I also feel for hyoid protraction. I have started assessing with water and graham crackers. If I need to, I will thicken the liquids, but usually wait for an instrumental assessment. I also have started using the 3 ounce water swallow challenge, which has been a good indicator for aspiration from what I have done so far.

 It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will treat. Another point that has been drilled into my head is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the amount of output in the muscle functions. Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink. Sensory input can also be established through tactile, thermal, or NMES input. In fact, Vitalstim placement 1 has the highest sensory input of all the Vitalstim placements. DPNS is highly driven by sensory input to the cranial nerves through use of frozen lemon swabs, along with thermal, tactile stimulation (TTS).

 You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for Frazier Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence.

 It is vital to assess motoric function. You treat the motor dysfunction, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment. There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal sqeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. I am extremely excited about the MBSImP which will be published next year with certification courses to follow!!

 The 3 ounce water swallow challenge is fairly new. It is an indicator of aspiration as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent. With this challenge, the person is given 3 ounces of water, either by straw or cup sip. They drink the water continuously. Any coughing, throat clearing or inability to drink all 3 ounces at one time is considered a fail. If the person can continuously drink the water and not cough during or for a minute after the challenge, they pass. Those that fail are then assessed instrumentally.

 Watching a person eat is also very critical to the evaluation. One predictor of aspiration is inability to self-feed. Medication can often affect a person’s ability to swallow, affect amount of saliva a person has to help break-down the food orally or affect the person’s alertness.

 A thorough dysphagia exam is vital and necessary for treatment. A good bedside examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.

It Takes A GOOD Therapist

I was sitting and thinking today. There are so many therapists that I have seen that are sub-par, (none of my friends of course!) It made me stop and think that every patient, client and student deserves to have the best of the best as far as therapy goes. I don’t want to take my children to a sub-par doctor, why shouldn’t I expect expertise from my therapist???

 Dysphagia, in that respect, is no different than any other specialty. In fact, dysphagia may be a little more so in needing expertise. Dysphagia is life and death most of the time. I’ve actually seen patients die from poor choices in diet and from upgrading too soon to an inappropriate diet. Residents in nursing homes have died from uneducated staff. This is not acceptable. This is my own personal list of what it takes to be a GOOD therapist, from a dysphagia perspective, of course.

 1. You need a therapist that is knowledgeable, to the point that the therapist can make any and all patients, client, etc. understand dysphagia. Every patient/client is entitled to understand their diagnosis and to understand the therapy you are providing. I can’t count how many patients have come to me for therapy, after having previous dysphagia therapy and never understood what the actual problem is!

 2. The dysphagia therapist should very much understand the process of the swallow. It’s not enough to know that people aspirate or penetrate and then give them a cookbook sheet of oral-motor exercises to complete every day 10 times, 3 times a day. The dysphagia therapist needs to know the muscles, the structures, the nerves and their functions.

 3. Don’t underestimate all the new treatments that are available. So many people will absolutely not touch VitalStim because “it’s not researched enough.” VitalStim and NMES is one of the most researched areas in our field. If you are able, go to these courses and learn what they are about. Read the literature. Make your own educated opinions. I always find that taking a little from each and every course that I go to, and putting it together to create my own therapy plan is more successful than the cookbook sheet of oral motor exercises.

 4. Do a COMPLETE assessment of each and every patient. It is not enough to simply sit with the patient at a meal and watch for them to cough or choke. You need to assess all the cranial nerves, do a complete chart review, palpate the structures and functions during the swallow. The 3 ounce water swallow challenge is a new assessment procedure that can give some valuable assessment data. Not so sure I completely believe in it yet, however am using it before all my MBS’s to test the validity on my own terms.

 5. When you complete an MBSS, don’t focus on aspiration, penetration, premature spillage, etc. Those are merely symptoms of a bigger dysfunction. You need to look at all the functions of all the structures and report on those. Yes, the person may aspirate, but why and what are you going to treat?? Bonnie Martin-Harris is publishing and providing CE courses next year on the MBSImP, which will be a standardized manner, in which to assess swallowing function during the MBS.

 6. NEVER, ever, ever upgrade a patient diet on a Friday, leave for the weekend, and come back on Monday to check how they are doing?? Doctors do not start a new medication then leave the person hanging for days on end. How can you functionally assess a person’s ability to manage the diet upgrade if you are not there to monitor??

 7. I so very often see therapists treat, by sitting with a patient at a meal, watching them eat, assisting with compensations and strategies and then doing the cookbook oral motor exercises with the patient. Don’t get me wrong, oral motor exercises can be functional, as a home exercise program in addition to ACTUAL swallowing therapy and compensations/strategies have their place, but they are not therapy. These compensations/strategies and OME do not promote the muscle changes required to constitute rehabilitation, which is what we do. You cannot improve the swallow without having the patient complete swallowing tasks.

 It is often debated, what do we, as SLP’s call ourselves?? Some demand Speech Pathologists, Speech Language Pathologists, Speech Therapists, etc. I prefer Speech Therapist, because I rehabilitate people.

 My challenge to everyone is to examine yourself and your therapy. Look at how you assess patients, how you complete the instrumental exam, how you treat patients with dysphagia. Ask yourself, what am I doing for my patient, what SHOULD I be doing for my patient and how can I do better for my patients, to rehabilitate their swallowing mechanism and therefore do my job and make my patient better??

Put Yourself in Their Shoes

My number one rule-of-thumb, especially when treating my dysphagic patients is to put myself in their shoes.

 First, I need to make this patient and their family member understand just what is going on. No, I don’t explain dysphagia in medical terms, but it is easy to put into layman’s terms when you understand the swallowing process. The patient needs to understand dysphagia, what is compromising their swallowing function and understand how and why dysphagia treatment will make them better and safer. Patients need to understand that this can be a life-threatening dysfunction but that it can be improved through therapy, diet modifications, compensations, etc.

 I also have to remember that one of the joys in life is eating. We all go through our day eating and drinking. It’s how we socialize, what we do at holidays. Our patients do not want to continue on a pureed diet with honey thick liquids when there is therapy available to possibly get them to a higher level. I’ve seen too many people discharged from therapy on an altered diet because the therapist has no idea what to do with them. I’ve also seen patients upgraded before they even really have therapy. Upgraded three days after the MBSS with severe dysphagia and aspiration is not an appropriate upgrade.

 Remember that our job as dysphagia therapists is to rehabilitate, or bring about change to the swallowing system and the musculature of the swallowing system. We cannot bring about change by sitting with a patient during lunch and reminding them to tuck their chin. We cannot bring about a change by having them stick out their tongue 30 times a day and think that’s going to improve the swallow. The only true exercise for the swallowing system is swallowing and challenging the patient with the swallow.

Exercise

Recent and some previous dysphagia literature emphasizes the use of exercise physiology. Researchers such Lazarus et. al, Robbins et.al, Burkhead et. al and Clark have published the need for incorporating exercise physiology into dysphagia therapy. They emphasize the need to understand the muscles involved in the swallowing mechanism, understand their function so that you can exercise those muscles in the manner in which they function for the swallow.

 The best way to work and improve the swallowing function is to swallow. Not only simply swallow, but push the swallow beyond it’s normal capacity. One way to incorporate increasing the load of the swallow is to use the effortful swallow, the masako or the Mendelsohn maneuver. The Shaker is a great load-resistant exercise to increase opening of the UES. These exercises have been researched and shown to be effective. Logmemann credits the research that has been established for the Shaker exercise and the lingual strengthening exercises from Robbins to increase lingual strength, with overall strengthening of the swallow.

 I’ve started an exercise approach to my dysphagia therapy. I started using almost like a “circuit” of swallowing training. I give the patient a list of exercises to complete while in therapy. Depending on what they need to focus their therapy, they complete a circuit of exercises. I use a variety of swallowing exercises including the Mendelsohn maneuver, effortful swallow, lingual resistance exercises, oral manipulation exercises. Most exercises include swallowing as part of the exericise. One of my favorite strengthening exercises is sucking pudding through a straw. I have the patient start with a regular drinking straw and work their way down to using a coffee stirrer. This not only strengthens the tongue, cheeks and lips, it also requires that they swallow. They spend x number of minutes of each exercise.

 Taking an exercise-based approach to swallowing is far superior to simply altering diet consistencies or adding compensatory strategies to each swallow. Rehabilitation should bring about a change to the swallow mechanism. I do not nor will I use compensations or altered diets in my therapy. I may put the patient on an altered diet, but I want to work the system naturally, not with a compensation if I can avoid it! Look to your PT and OT departments. They work the muscles to bring about change and we should be doing the same.

 Logemann, J.A. (2005). The Role of Exercise Programs for Dysphagia Patients. Dysphagia. 20: 139-140.

 Clark, H.M. (2005). Therapeutic exercise in dysphagic manamgent: 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 adn dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language and Hearing Research, 51: S276-S300.

 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. American Journal of Speech-Language Pathology, 12: 400-415.

 Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L. and Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 52, 1483-1489.

 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 Phoniatrice et Logopaedica, 55, 199-205.