“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.

Continue reading

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!!

Carbonated Beverages

carbonated

Carbonated beverages have hit the dysphagia world by storm.  Much of the recent dysphagia research has focused on the sensory portion of the swallow and how sensory drives the swallowing process.  Part of the sensory process is carbonated beverages.  One of the common misconceptions at this time is that carbonated beverages act as a nectar thick liquid.

Carbonation is a sensory option for dysphagia rehabilitation.   It’s effective through a process called chemesthesis, where the “bubbly” or “fizzy” of the carbonated beverage acts as a Trigeminal irritant.  The Trigeminal Nerve or Cranial Nerve V is one of the major swallowing nerves.  The Trigeminal Nerve has bare nerve endings making it more susceptible to sensory or afferent input.

Rather than acting as a nectar thick liquid, the carbonated beverage actually increases the sensory stimulation for the swallow.  Sensory input (afferent drive) drives the motoric output (efferent drive).

Research of carbonated beverages shows:

No significant effect on oral transit time, pharyngeal transit time, initiation of pharyngeal swallow or pharyngeal retention.  Carbonated beverages sis however decrease penetration/aspiraiton with 5 & 10 ml swallows.  (Saravou & Walshe).

Carbonated thin liquid significantly decreased the incidence of spillover, delayed pharyngeal response and laryngeal penetration compared to non-carbonated thin liquids.  (Newman et al).

Drinks containing chemical ingredients that activate sour and heat receptors alter swallowing physiology greater than water.  (Krival & Bates).

It is likely that sour and carbonated beverages reflect a more organized activation of the submental muscles because of more effective afferent input to the Nucleus Tractus Solitarius.  (Miura, et al).

One of the important issues to consider when looking at research involving carbonated beverages is that the researchers in these studies do not use Coke, Pepsi or Sprite.  They use Ginger Brew, Club Soda or carbonated citrus.

It is vital, as with any other compensation or technique to view the effects of carbonated beverages.  As with other strategies, you may not see the same effect in every patient and sometimes, the strategy you choose may make the swallow worse.

Krival K, Bates C. Effects of Club Soda and Ginger Brew on Linguapalatal Pressures in Healthy Swallowing. Dysphagia (2012). 27: 228-239.

Newman, et al. Carbonated Thin Liquid Significantly Decreases the Incidence of Spillover, Delayed Pharyngeal Response and Laryngeal Penetration Compared to Non-Carbonated Thin Liquids. Dysphagia 2001: 16: 146-150.

Saravou K, Walshe M. Effects of Carbonated Liquids on Oropharyngeal Swallowing Measures in People with Neurogenic Dysphagia. Dysphagia(2012) 27: 240-250.

Miura, Yutaka, et al. “Effects of taste solutions, carbonation, and cold stimulus on the power frequency content of swallowing submental surface electromyography.” Chemical senses 34.4 (2009): 325-331.

The Patient Exercising Their Right to Choose (Formerly The Non Compliant Patient)

patient

EDIT 1/4/17.  Due to a recent Facebook post, I wanted to change some wording on this post.  As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.

Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”  

There was post recently on the Special Interest Group (SIG) 13 email blast.  An SLP was asking what to do with a noncompliant patient.

When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged.  The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.

My belief system is not the same, fortunately for my patients!

First, think about this.  Aren’t the noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about?  The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make.  They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe.  The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety.  That is the patient that may be most at risk for aspiration pneumonia.

In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity.  I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.

The best thing we can do for our noncompliant patients is to educate and rehabilitate.  Why not make them safer with the consistency they choose?

The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care.  If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow.  I recently wrote a post about oral care which you can find here.

It’s important to remember that we want the patient to succeed with the diet they choose to consume.  We can recommend a safe diet and we can advise but we have to focus on the rehabilitation.  Just remember, not everybody that aspirates develops aspiration pneumonia.  There are functional aspirators.

You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia.  Just because that patient does not choose the diet you recommend does not mean you give up on them.  If they are willing to put in the work and give you some time (they will have to buy-in to your program)  THOSE are absolutely  patients with whom we should work.

Supraglottic and Super-Supraglottic Swallows and Tongue Pressure-Research Review

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Fujiwara, S, Ono, T, Minagi, Y, Fujiu-Kurachi, M, Hori, K, Maeda, Y, Boroumand, S, Nitschke, I, Ursula, V, Bohlender, J.  Effect of Supraglottic and Super-supraglottic swallows on Tongue Pressure Production against Hard Palate.  Dysphagia (2014) 29:655-662.  

The Super- and Supraglottic Swallows are maneuvers used to assist in early airway closure to prevent food or drink from being aspirated prior to the swallow.  

Participants:  19 healthy young staff members of the University of Zurich Dental School (13 females, 6 males) with an age range from 17-40.

Equipment:  Tongue pressure measurements were recorded using the Swallow Scan System using a pressure sensor that forms a “T” shape following the curve of the palate.  Participants were seated upright with their heads immobilized by  a head rest.  

Procedure:  This study looked at normal swallow, Supraglottic Swallow (ss) and Super-Supraglottic Swallow (sss).   Each participant swallowed 5 ml of water at room temperature.  For the SS, a syringe was used to inject 5 ml of water into the floor of the oral cavity with the instructions “breathe through your nose, then hold your breath lightly before and during swallowing.  Cough immediately after you finish swallowing.”  For the SSS the same procedure and instructions were given, plus the additional instruction to put the palms of their hands together in front of their chest and press them hard against each other while they held their breath.

Results:  The perimeters measured  were:  duration, maximal magnitude and integrated value of tongue pressure during swallowing.  “The duration of tongue pressure was significantly longer at the anterior-median part of the hard palate during both SS and SSS than with normal wet swallow.  The maximal magnitude increased significantly only at the posterior part of the hard palate during SS, but at all points during SSS.”  Not only do the SS and SSS increase protection of the airway prior to the swallow, they may also function to strengthen the tongue.  

In the News-Seen around the Web

Find out why it’s harder to swallow after the age of 50!

coffee

Nearly 40 percent of older Americans are living with a swallowing disorder known as dysphagia.

Although it is a major health problem associated with aging, it is unknown whether the condition is a natural part of healthy aging or if it is caused by an age-related disease that has yet to be diagnosed, such as Parkinson’s disease or amyotrophic lateral sclerosis (ALS).

Following a recent study, researchers at the University of Missouri have established a model that identifies aging as a key factor in the development of dysphagia, which may lead to new therapeutic treatments.

“As people age, and especially once they’re 50 and older, their ability to swallow quickly and safely deteriorates with each advancing decade,” says Teresa Lever, assistant professor of otolaryngology at the School of Medicine and lead author of the study.

“For years, we haven’t known why. Through our research with mice, we now know this disorder can occur naturally and independent of another disease.

“Our next step is to study this model to determine why age-related dysphagia, also called presbyphagia, occurs and identify ways to prevent it.”

Pneumonia Risk

Individuals with presbyphagia generally experience slow, delayed, and uncoordinated swallowing that compromises airway function. This puts older individuals at risk for developing life-threatening malnutrition and aspiration pneumonia, which is caused when food or saliva is breathed into the lungs or airways.

These risks are increased when an individual has an existing health condition, such as a neurodegenerative disease, head and neck cancer, or a major surgery.

Videofluoroscopy has long been the gold standard for diagnosing swallowing disorders in humans. A video fluoroscopic swallow study is a radiologic examination of an individual’s swallowing function that uses a special X-ray device called a fluoroscope.

The patient is observed swallowing various foods and liquids mixed with a contrast agent that can be seen by fluoroscopy in order to evaluate his or her ability to swallow safely and effectively.

Same Symptons in Mice

However, because a long-term study of the swallowing ability of an individual as he or she ages is unfeasible, Lever and her research team studied the swallowing function of healthy mice throughout their approximate two-year lifespan.

“We have a miniaturized fluoroscope and swallow test protocol that are unique to our lab that we can use to determine if a mouse has dysphagia,” Lever says. “By studying the swallowing function of healthy mice over their lifespan, we found they exhibit many of the same symptoms of dysphagia as healthy aging adults.”

15 Signs and Metrics

The researchers established 15 metrics that could be compared to human swallowing function. These metrics include functions such as swallow rate, pharyngeal transit time—the time it takes liquid to be swallowed through the pharynx , or throat, and into the esophagus, or food tube—and the number of ineffective swallows through the esophagus.

The researchers found that healthy aging mice develop symptoms of swallowing impairment that closely resemble the impairments seen in older adults: generally slowed swallowing function, impaired tongue function, larger size of the amount swallowed, and an increase in the time it takes liquid to travel through the throat to the stomach.

“We’re about to change the landscape of dysphagia intervention,” Lever says. “For years, we’ve only been able to treat the symptoms and have been unable to address the root causes of dysphagia.

“Though more research is needed, this knowledge sets the stage for us to study ways to prevent, delay or potentially reverse swallowing disorders using new therapies.”

The study was published online by the journal Dysphagia. Funding from the University of Missouri and the National Institutes of Health helped support the project.

Source: University of Missouri Republished from Futurity.org under Creative Commons License 4.0.

*Image of “coffee” via CIAT/Flickr

Source:  http://www.theepochtimes.com/n3/1315567-why-its-harder-to-swallow-after-age-50/