“Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes”

If you are considering joining or starting a head and neck cancer program, this is the read for you!

I was searching through articles this morning and found this very article stating the importance of a team approach and a systematic approach to head and neck cancer!

“Head and neck cancer guidelines recommend multidisciplinary team monitoring and early intervention.”

Prophylactic treatment for head and neck cancer has been found to increase maintenance of tongue muscle mass, preserve some taste and have an overall improved swallow.   The SLP should be right in there, from the beginning to determine baseline swallowing function and to provide education for what may happen to the swallow.

“We need patient care using a systematic approach for head and neck cancer.”

Read the research.  Keep up with the new approaches and utilize them in  your therapy.  Dysphagia assessment and treatment approaches are ever-evolving and you have to stay current to provide your patients with the best care possible.

With the multidisciplinary Approach:

  • Improved outcomes
  • Better survival rates
  • Maximize results through use of a coordinated pathway
  • Increase efficiency in care delivery
  • Reduce cost
  • Shorten the length of the hospital stay
  • Improve overall patient outcomes

Who should/may be on the multidisciplinary team:

  • Head and Neck Surgeon
  • Medical Oncologist
  • Radiation Oncologist
  • Nursing
  • Speech Language Pathologist
  • Dietician
  • Social Worker
  • Administrative Professionals (Systems Analyst, Clinical Research Coordinator)

“A significant impact of Head and Neck Cancer is typically the impact on swallowing and inadequate nutritional intake.”

The SLP plays a vital role in the assessment and treatment of swallowing.

“Prophylactic and ongoing Speech Language Pathology services can be vital by impacting swallow function, nutritional status and overall quality of life.”

We’re not just one and done.  Even though the patient may not initially have difficulty with swallowing early in their treatment doesn’t mean it will never happen.   You need to check up on the patients throughout their course of treatment and even after their treatment to continue to assess the impact on swallowing.

Collecting Data:

Patients undergo a pre-treatment MBSS (Modified Barium Swallow Study) and/or FEES (Flexible Endoscopic Evaluation of Swallowing).  Also completed with patients:

Prophylactic Exercises Included:

  • Lingual strengthening
  • Masako Maneuver
  • Effortful or Supraglottic Swallow
  • Mendelsohn Maneuver
  • Shaker
  • Therabite (incisal opening less than 40mm)
  • EMST (increase airway clearance/protection)

*Exercises completed 2x/day, 6 days/week

References:

Dance Head and Neck Clinical Pathway (D-HNCP)

Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M., Silinonte, J., … & Sobel, R. (2019). Establishing a multidisciplinary head and neck clinical pathway: An implementation evaluation and audit of dysphagia-related services and outcomes. Dysphagia34(1), 89-104.

 

The Medical SLP

The Patient

Being a medical Speech Language Pathologist (SLP) is quite different than working in a school.   Most people know that an SLP working with children often work on sounds that are produced in an incorrect manner or language skills.  The SLP may also help with reading and reading comprehension.

 

Did you know that an SLP can also work on social skills with students who have difficulty with appropriate interactions with others?

 

An SLP may work in a pediatric hospital and work with babies and children who have swallowing difficulties.   Many babies in the NICU require SLP services to learn to eat or suck using a bottle or even with breastfeeding.

 

As a medical SLP, I really believe the most common phrase I hear is…..”I don’t need speech therapy.  I talk just fine.”  Seriously, if I had a penny for every time I heard that, I could retire in style.

 

Our name is very misleading and barely touches on the wide array of deficits the SLP can rehabilitate.  Many SLPs have speech and language in their title, but never work with either.

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3 Reasons You Should Never “Fake it Till You Make it” in Dysphagia

I really don’t know where the phrase “fake it till you make it” came but it’s one phrase that absolutely makes me cringe in relationship to dysphagia.

Don’t get me wrong.  You should always go in confident in your skills.  How can you possibly be confident though in skills you don’t possess?

The scary part is, with dysphagia, if we don’t know what we are doing, but go in to diagnose and treat on the “fake it till you make it approach” we can play a key role in the person’s death.

Not necessarily that the person even chokes on something.  When we change a patient’s liquids and thicken the liquids, the person can then experience dehydration, sepsis, UTI or a multitude of other effects.

So let’s get to it.  The THREE reasons why you should never fake it till you make it in dysphagia therapy.

Reason One

It’s actually against our code of ethics provided by ASHA.

“Individuals shall not misrepresent their credentials, competence, education, training, experience, and scholarly contributions.”

When we “fake it” we are actually telling patients that we are competent in an area that we may not have a clue and misleading that patient.   Ideally, we should help that patient find a competent clinician if you do not feel that you fit that bill.

Reason Two

How can you assess and diagnose what you don’t know?

Yes, we diagnose dysphagia.  This is the reason we are Speech Language Pathologists in the US.  We are able to diagnose a range of speech and swallowing related disorders.

If you don’t understand the normal swallowing process and know the deficits, how can you possibly diagnose dysphagia?  Did you know that when a diagnose is given to a patient, that diagnosis stays with the person.

Misdiagnosis often leads to inappropriate diet changes, unnecessary therapy services and possibly secondary issues that can arise from those inappropriate diet changes.

I mean, do you really know any person that has been excited about having thickened liquids?  Have you ever had a patient comment on the amazing taste of thickened liquids?

What if you are the person responsible for the Modified Barium Swallow Study (MBSS) or Flexible Endoscopic Evaluation of Swallowing (FEES)?  Do you know how to complete the test or interpret the test.  If the answer is no, then you’ve just wasted, money, time and effort.  Accurate completion and reporting of either of these assessments is vital in diagnosing, referring or providing treatment for dysphagia.

Reason Three

Just like you can’t assess and diagnose dysphagia, how can you possibly treat dysphagia when you don’t understand it.

I mean sure, you can throw a list of exercises at a patient, you can modify the diet, but what are you doing for the patient?   What are you actually accomplishing with this patient?

This patient is relying on you to be the expert, to be honest with them and to help them with an issue that is a major roadblock in their recovery.

What can you do?

Don’t turn to social media the night before an evaluation or treatment session knowing nothing about the disease process, the assessment or the treatment protocols.

If you are interested in dysphagia but don’t feel comfortable or confident in dysphagia, find a mentor, read journal articles, shadow, read textbooks.  Learn everything you possibly can about dysphagia.

Be honest with your patient.  I am terrible with fluency.  If I have a referral for a patient with dysfluency, I will more than likely refer them out to an SLP with more experience.  It’s the right thing to do.

Hold paramount your patient’s best interest and never, ever “fake it till you make it.”

  • Tanner, D. C. (2010). Lessons from nursing home dysphagia malpractice litigation. Journal of gerontological nursing36(3), 41-46.
  • American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists performing videofluoroscopic swallowing studies.
  • American Speech-Language-Hearing Association. (2002). Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders.
  • Boaden, E., Davies, S., Storey, L., & Watkins, C. (2006). Inter professional dysphagia framework. University of Central Lancashire, Preston.
  • McAllister, L., & Rose, M. (2000). Speech-language pathology students: Learning clinical reasoning. Clinical reasoning in the health professions, 205-213.
  • Kamal, R. M., Ward, E., & Cornwell, P. (2012). Dysphagia training for speech-language pathologists: Implications for clinical practice. International journal of speech-language pathology14(6), 569-576.
  • ASHA Code of Ethics www.asha.org

Be the Change

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Let’s face it, we’re not all leaders. Some of us are happy going to our jobs and just done at the end of the shift. Many of us tend to get on social media and complain about issues that we feel are out of our control.

The problem is that just voicing our concerns on social media does not solve the problems. We have to look beyond ASHA and our boss to make these changes.  Now don’t get me wrong, ASHA, management, your state association can be a great start.

You might be asking what are some of these gripes and complaints. Productivity is the big one. We are often asked to work billable time for the majority of our day not allowing us any break for consultation or paperwork that is required of us.  How many of us go in to work,  clock out to maintain our productivity while completing paperwork, making phone calls or some of the necessary but not billable time possible while maintaining 90% productivity or more.   Maybe the reason the productivity expectations exist and the reason that it keeps getting higher is because people are actually meeting these standards. When we give 100% the next expectation will be 110%.

So maybe we can sit and stew about the fact that I’m working on my own time or maybe I can join my state association or ASHA and help bring about change to that productivity.

Another frequent complaint is the lack of instrumental assessment.  Some facilities will not allow instrumental assessment,  however have you presented the cost associated with an pneumonia or with any re-hospitalization compared to the cost of an instrumental assessment?  How can you possibly build an accurate plan of care for your patient when you can’t assess your patient?

When we actually think outside the box that’s when we can get things done.

Continue to educated yourself.  Stop being so complacent with your job.  Stop using non-evidenced based practice and the same oral motor exercises that have been used for 25 years.  Keep up with new practices.  Be a champion and advocate for yourself and for the profession you hopefully love.

When you start standing up for yourself and demonstrating efficiency and competence in your job is when we can show other medical professionals the value in the Speech Language Pathologist in the area of dysphagia.

Stop just posting to gripe on social media and make a change!!

Measuring Lingual Range of Motion

For so long, we have focused on lingual strength and range-of-motion.

The Iowa Oral Performance Instrument (IOPI),  the SwallowStrong and the Tongue Press have all been developed to give us visual and numeric strength measurements of the tongue.

We finally have a measurement scale for lingual range of motion.

C.L. Lazarus, H. Husaini, A.S. Jacobson, J.K. Mojica, D. Buchbinder, K. Okay, M.L. Urken.  Development of a New Lingual Range-of-Motion Assessment Scale, Normative Data in Surgically Treated Oral Cancer Patients.  Dysphagia (2014) 29:489-499.

This study compared results in treated surgical patients vs. healthy patients.   36 patients s/p oral tongue surgery with significantly decreased tongue range-of-motion and 31 healthy individuals.

The scale was validated by correlating range-of-motion with performance status, oral outcomes and patient-related Quality of Life.

The scale was made to define lingual deficits.  This is a tool that can be used for baseline and post surgery tongue range-of-motion and to track changes over time with recovery and therapy.

Lingual protrusion was measured using the Therabite jaw range-of-motion measurement discs.

Protrusion Scores:  (100) Normal:  > or = 15 mm past the upper lip margin

(50)   Mild-mod:  >1mm but <15mm pasat the upper lip margin

(25)   Severe:  Some movement but unable to reach upper lip margin

(0)     Total:  No movement

Lateralization Scores:  based on ability of the tongue to touch the commissures of the mouth.  Measure both right and left side.
(100)  Normal:                      able to fully touch the corner of the mouth.
(50)    Mild-Moderate:  50% reduction of movement to corner of the mouth                                                in either direction.
(25)    Severe:  >50%           reduction in movement.
(0)      Total:                          No movement.

Elevation Scores:    

(100)  Normal:  complete tongue tip contact with the upper alvoelar                                       ridge.
(50)    Moderate:  tongue tip elevation but no contact with the upper                                       alvoelar ridge.
(0)      Severe:  No visible tongue tip elevation

Total Scores were assigned by adding the protrusion score+ right lateralization score + left lateralization score + elevation score divided by 4.

Scores were 0-100:      

0=severely impaired/totally impaired
25=Severly impaired
50=mild-moderate impairment
100=normal

During this study, tongue strength was measured using the Iowa Oral Performance Instrument.

Jaw range-of-motion was measure using the Therabite jaw range-of-motion measurement discs.

Saliva flow was measured using the Saxon test where the patient was asked to chew a sterile 4×4 piece of gauze for 2 minutes then spit the gauze in a cup.  The gauze was weighed before and after mastication.

The Performance Status Scale was used to determine diet type, speech uderstandability, impact of surgery on ability to eat socially.

Quality of Life was measured using the Eating Assessment Tool-10 (EAT-10), MD Anderson Dysphagia Inventory (MDADI) and Speech Handicap Index (SHI).

The study found that lingual range-of-motion can negatively affect all aspects of a patient’s life and correlates with performance and quality of life.

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??

My Patient had Their Modified, Now What Do I Do?

Once upon a time, I worked in a setting and had to send my patients out for the MBSS. Now, I am able to complete my own MBSS. One thing I take into account when I am doing an MBSS for another SLP is making sure they get a complete study. I have actually gone to several CE courses regarding MBSS in the last 2 years. When I say a complete MBSS, I don’t mean that I test 15 different foods using every strategy known to man per spoon, cup, straw, syringe or whatever else I can think of to feed the patient. When I say complete, I mean that I try to find the dysfunction, the abnormality of the swallowing mechanism. I used to get those reports that stated patient so and so aspirated thin liquids with non-functional cough, chin tuck did not eliminate, blah blah blah. That doesn’t tell me WHY the patient is aspirating and what I need to focus my therapy on to STOP the aspiration.

 If you are one of those clinicians that have to send your patient out and rely on another clinician to complete your MBSS there are ways to interpret what the therapist is writing into muscle dysfunction.

 First, let’s look at the oral phase. You have to look at lip closure. You know that if the person drools or has anterior spillage of the bolus, there are probably some labial seal issues, so you are going to work some on that orbiularis oris and labial seal with resistive labial exercises. The tongue has to move the bolus from side to side, recollect the bolus on the tongue and push it back, pushing up against the palate to create pressure to push the bolus. If the patient has poor bolus formation, residue in the sulci, premature spillage, they are probably not getting good bolus formation, they probably have a weak tongue. If there is reported residue on the tongue and/or palate, they probably are not getting enough tongue-palate contact. You are going to work on resistive lingual exercises. Pocketing in the lateral sulci will indicate poor buccal strength, decreased tension. Resistive cheek exercises are a must.

 Premature spillage can indicate that back of the tongue is weak and the tongue is weak and not holding the bolus in a cohesive manner. Again, resistive lingual exercises, Masako, effortful swallow will all focus on the back of the tongue. Pharyngeal residue will always indicate decreased tongue base retraction and may indicate decreased pharyngeal stripping wave. Again, to strengthen that part of the swallow, I use the effortful swallow, large, thick bolus swallows. Penetration/Aspiration is going to indicate poor hyolaryngeal excursion, which can be any of the three areas including anterior motion of the hyoid, laryngeal elevation and hyoid/thyroid approximation or laryngeal closure. There is really quite a bit of information needed here, how long does the closure last, when are they aspirating. However, if all you get is penetration and/or aspiration you know you need to work on airway protection through the effortful swallow, lingual strengthening (it is attached to the hyoid, which is part of the excursion), Mendelsohn Maneuver. You will also have evidence of decreased airway protection through evidence of decreased epiglottic inversion. If you get a report of pyriform sinus residue, there is possibly an issue with Pharyngeal Esophageal Segment (PES/UES) opening. Now, the PES is opened through Hyolaryngeal excursion and the force of the bolus. The bolus is pushed through the oropharyngeal region by pressure of the tongue, so for PES opening issues, I work on lingual strengthening, Shaker, Mendelsohn, effortful swallow and change the bolus size and consistency.

 Many times, I have observed therapists altering patient diets, teaching chin tuck, double swallow, etc. While I agree that we have those patients that diet alterations, compensations are appropriate, we also have those patients that have the potential for rehabilitation that don’t want to look at their lap every time they swallow. I know I wouldn’t want that.

 As therapists, we have to become better at not only investigating and determining the dysfunction of the swallow, but at writing the report so that other clinicians can TREAT the dysphagia. We don’t treat symptoms. I can’t treat aspiration. In fact, many people CAN, in fact have dysphagia without aspiration or penetration. Think of how short a time we have the patient in radiology. Who knows that they weren’t going to aspirate the next bite that we never gave. We can, however, determine that the patient has decreased laryngeal elevation, with or without penetration/aspiration and TREAT that. We can determine that the patient has decreased lingual strength, (which will probably affect a huge portion of the swallow) and TREAT that.

 My modifieds have changed drastically. I don’t test every consistency. I test thin, nectar, honey-if absolutely necessary, pudding and cookie. I’m not looking for every consistency and what they do with it. I’m looking at the dysfunction of the swallowing mechanism. Once we start doing that, we become competent in what we do.