The Orlando shuffle

Here at the 2014 ASHA convention. What is your goal? Why are you here? What will you get out of 3-4 days of sitting in large and cold lecture halls, then dashing down corridors and fighting large waves of fellow travelers - ? I really did ask myself those questions, the day before the Convention had begun. A Convention Center hugely dependent upon Florida car culture - not that accessible by foot or by mass transit. Unless you were housed at one of the nearby Convention hotels, connected by either footbridge or shuttle bus, - it was a car commute through rather messy rush hour traffic. Ahhhhhh - but I was not driving: the Convention Center emerging from the swampy foreground; my hands rifling quickly through the canvas bag holding my convention tools: badge on lanyard, legal pad, convention program, and some high energy snacks for those mid-afternoon blood sugar crashes. The ride screeches to the drop off point, and like a Navy Seal you VAULT out and briskly stride into the convention center hallways. This formula has worked well for at least the past fifteen years at ASHA Conventions. This daily inter-session spring is a major undertaking: suddenly swerving swarms of professionals who are clustering, zooming and buzzing between meetings - coming straight at me! YIKES! Luckily my years of speed walking through the Chicago Loop District, dodging and passing commuters and others to and from work; - that skill has held me in good stead. WHOOPS SORRY....! But, the questions. I have been practicing speech-language pathology for over 30 years. What could the Convention do for me, at this stage of my career?? My first ASHA convention was in 1974, in Las Vegas. ASHA has not held a convention in that city after 1974. What effects have the years brought on the profession - and on me?

There are advances in pure and applied research that need be reviewed. For example, life participation approaches to neurogenic disorders like aphasia: how - in spite of being chronically and perhaps, severely disabled from brain damage that limits your speech and language, you are out living life to get the highest quality you can. Such as, participating in book clubs or computer clinics. Surface EMG for dysphagia, means that swallow functions are often trainable with the biofeedback capacity of this unit. And, because of proposed changes for reimbursement by Medicare for "speech generating devices" (SGD's), persons without the use of speech for everyday communication are deprived of technology that limit the quality of their lives. These examples are only a few of the hundreds of topics that were covered in Convention sessions. Why aren't the data obtained from the sessions in this blog post? 

This is a blog, with the content more the observations and opinions of the writer than a strict reportage of the events. I feel that life participation approaches are one of the best collections of tools and resources for SLP. If you accept that persons with aphasia can ultimately have vital roles in the life of their communities, even with chronic problems communicating - then you have ultimately some exciting career options, in giving assist to these people in real world environments. Treating swallowing issues with surface EMG allows the clinician and the person served to obtain rapid data series, to immediately judge the effectiveness of treatment trials. Did you know that persons with SGD's who had previously had full control of the computers unlocked by the dealer - that the persons will LOSE that capability, with the new Medicare regulations fully implemented?

There are numerous social and professional events, in addition to the educational sessions at Convention. It is the annual 'gathering of the clan', after all. Some of the changes over the years are more accommodating than others: the opening session pre-empts lectures for the initial 90 minutes of the first day; the box lunches that can be ordered for pickup each day in the exhibit hall; the shrinkage of the University open house parties, and the total elimination of the Convention dance! Through it all, Convention remains a don't miss event each year. It is my annual vacation time. It is my professional recharging time. It is also my professional growth time, as I have presented papers on horticulture, swallow screening and aphasia pharmacotherapy at ASHA. When November comes around, my canvas bag is packed and I'm ready to go.

You Are the Most Important Person

I started mentoring young professionals in the profession of communication sciences and disorders (CSD), in the late 1980's. I had been in a hospital job for a few years, with acute rehab, acute med, SNF, outpatient, home health and hospice among our services. Needless to say for many readers of this blog, we had a steady demand from master's students in the nearby CSD training program. It's been my good fortune since then to mentor more than a score of women and men, entering the field of CSD: whether a shadow during undergraduate years, a participant in ASHA's STEP program, or an intern prior to receiving the master's degree - they have all taught me a lot.

* the mentor does not have to be infallible - In these days, all the digital interconnections in our world allow persons with Internet savvy the ability to answer content questions. So, if the mentee needs to know  the efficacy of melodic intonation therapy, there may be little need for the mentor to actually provide the answer. Where the mentor will lend expertise is in framing the search terms for the answer: "efficacy of MIT w/ global aphasia"; "MIT short form"; "MIT and return to work for persons w/ nonfluent aphasia ";  - only one example of how the mentor may help hone the mentee's thinking on her/ his feet.

* a thinking mentee is a fearless mentee - the workplaces for CSD professionals  are constantly changing,  as the economic forces supporting their operation convulse and change.One day procedures in the worksite will require response "A" from the clinician, and the next day they are clamoring for your response to be "D". The mentor can be of assistance through contacts with the American Speech-Language-Hearing Association (ASHA), the credentialing and advocacy organization for professionals in CSD. When ASHA staff are able to give the working clinician advance word of  changes in reimbursement policy, or in development of regulations affecting practice, the mentee may adapt to the changes with more confidence. In numerous instances the mentor can help the mentee learn proactive,  evidence-based abd easily-expressed  action in the daily grind. which reminds us that -

* the relationship comes first - when a mentorship begins, how the dyad communicates sets the tone for how the mentee achieves her/his goals. The trust,
The clarity, feedback, and the focus and planning for the duration -they all begin with the formation of the mentor - mentee relationship. What the mentor seeks to give the mentee is not so different from what happens, at the first meeting of clinician and client in the CSD treatment setting -

* you are the most important person to me now -  at this moment, I am solely focused on you, and what you need is my top priority. I will be ethical and open throughout. I am committed to your great future.

My Swallowing Is My Business

Here's an illustration of one component of what I have called "organic SLP": teach, teach, teach. An actual teaching handout given to an actual patient - with the aim of the consumer of clinical service, taking action to prevent disability when possible. One way to do that, is to understand normal function. Feedback as always is VERY welcome!

I don’t have to think about swallowing most of the time. I started swallowing before I was born.

Scientists have found that the human fetus swallows at age 15-16 weeks. I developed my first taste preferences in the womb. After I was born, I was fed and then learned to feed myself, by learning all the skills to get food in my mouth.

Sitting up in a chair, or standing, seemed to be the positions where swallowing was done most often. When I was a kid, I also ate in every other position because – I could!  I ate upside down; lying flat while watching TV; - I even ate while spinning in a carnival ride!

But, as I got older, my swallowing seemed to work more easily when I was upright.

My swallowing happens because I use some muscles voluntarily, and because of other muscles that work without my thoughts. The voluntary muscles are controlled in this

  part of my brain.

 The muscles that work automatically   are controlled by this part of my brain.  So, even though I can control some parts of my swallowing and change part of the swallowing act, all the swallows I have done over my lifetime have made the way I swallow a strong pattern of habits.

Here is how I do it. Here are my habits:

I pick up the food with my fingers or a utensil. When I take a drink, I use a teaspoon, a cup or a straw to put it past my lips.

I hold the food or liquid on my tongue, and form it into a shape that can be squeezed back or chewed, until it forms a more slippery and sticky shape (left illustration).  The squeezing gets the material to the back of the tongue, where my control over swallowing changes. The swallow “triggers” there (right illustration) and pushes food or liquid into my throat. When the material goes DOWN, the voice box lifts UP. What I swallowed moves down past the voice box and pushes open a valve into the esophagus.  My swallowing is totally automatic at this point. Before the material goes into the esophagus, I can use my tongue to affect what happens to the food or liquid. In the esophagus material travels in waves of squeezing, down to the stomach.

There. That is my swallowing. It is my business to swallow well, because I eat to live. I eat to feel satisfied. I eat to be with others. My body, my business. 

It's too dry

If celebrity chef Gordon Ramsey had been served this, he'd have sent it back - flying through the air and lifted by some choice curses. The people who do often get served dry proteins at mealtimes, will - the odds dictate - NOT return the food they get. Even though the meat or fish they are served may be hard, colorless, not easily sliced or diced, and even less aptly chewed and swallowed - a certain customer base will let that protein suffice. Who are these unsophisticated patrons? Largely, they are patients and residents of post-acute hospital, skilled and long term care facilities. Whatever the type of the facility, the persons who are housed there will have to eat there. One of the most frequent complaints heard about long term care meals, is that solid foods are dry and lacking in flavor. What is the problem?

Irregardless of the cooking skill of the dietary staff in this facility, when solid foods are presented to the person served as dry and unappetizing - their consumption flattens. With all of the diets for person served in a facility, foods served are for persons with GI problems, respiratory problems, cardiac problems, kidney problems, diabetes, neurological problems - and many more problems. Overlaid on the need for special and modified diets are the person's needs to take medications and supplements for their medical treatment. A person who takes multiple medications by mouth is more likely to experience dry mouth as a symptom. When a dry mouth is more the norm, there is less of a chance to chew and swallow dry foods successfully. Choking on dry foods in a dry mouth raises red flags for the treatment staff; namely, nurses and staff - to alert treatment staff there is someone with a swallowing problem - !!

Given that the problem as presented is multifactorial; that is, not caused by a single variable in the nutrition process; -  a person that has a so-called 'swallowing problem' may instead be dealing with a 'cooking problem'. Perhaps changing how the food is prepared - in the kitchen or tableside - will give more persons options for making institutional food palatable. The next post will give you some solutions to this dilemna.

Organic SLP: An attitude or a science?

When you think of how SLP's work; where we do our work; and about the processes and the goals for our work - is organic SLP, science? Can the results of clinical practice that stresses communication for relationship-building, over drill work to increase component communication; the use of environmental structures and cues to make it easier for a person to function well;  the primacy of applying component skills for cognition, communication and swallowing, in the settings where they will be used; where rapid acquisition of goal targets is stressed; where customer satisfaction is accentuated through teaching and obtaining frequent feedback - be replicated across ages, disorder types and treatment settings?? Is organic SLP, science??

I would say, yes - that organic slp IS built upon a scientific framework, and that its principles can be upheld alongside the practice of what I have called "mechanistic SLP".The clinician who uses organic SLP principles has her/his roots in mechanistic SLP; namely, the tools for impairment-based evaluation and treatment can and should be used. There are scores, hundreds of incidences where a person with a cognition or communication problem would only begin to change when slow, methodical and segmental training of processes occurred. Impairment-based training is the core of our field, and the skill sets inherent in our clinical training will always be in that bag of tricks we scour before each encounter.

There does remain a need in SLP clinical practice, for a skill set that brings the person served from an entry point of dependence to that of relative independence as quickly as possible; that allows the SLP in an interdisciplinary practice setting (e.g. with physical and occupational therapy, or with education and psychology) to assert her/his expertise as vital to the successful outcome of the person served; that models for all the professionals involved with a person, superior customer service; that constructs a strategy system allowing the person to say: I can do this in real life when I - , and that treats communication processes largely where the processes will be used day-to-day. How can these additional be measured and evaluated, as having met the tests of scientific method?

The SLP clinician has the skill set to operationally define organic SLP processes, and to write targeted goals for treatment after baseline status is clearly described. For example, the person served may gain attention of a caregiver from across the room, using speech and gestures in a noisy setting, 25% of the time. Barriers to the person performing this function include the noise level ( TV on, dishes clattering, chatter within the room, PA system occasionally carrying announcements, person's weak voice and impaired hearing). Treatment includes identifying the components controlled, then controlling them as possible. It also includes compensating for the variables that cannot easily be controlled. How would you help the person increase her/his skill?

Gotta laugh

In the recent post "Organic SLP", I hinted that this style of practicing speech-language pathology (SLP) was very different from a style that I called "mechanistic SLP". Where mechanistic SLP meets persons served  where their bodily functions breakdown, organic SLP deals with the needs of persons in real life situations. When it comes to dealing with stressful real life situations, such as a person served who is feeling anxious or depressed, it is the SLP who may often lead the way for the person's improvement. Sometimes, a good belly laugh may start the healing.

I once worked with a man who had had a stroke, done his rehab and gone home. He then had come back to our rehab center, after the trial at home had been disastrous. He had lost his skill with walking, and lost much weight in the bargain....and with his clinical signs of depression seemingly sinking him at the beginning, there was a need for immediate change in his focus.

Why did I feel I was the ideal person to get him refocused? I had made a reputation in previous jobs, as the staff who would take on the most challenging "patients" around. I had been kicked, bitten, wrestled, punched, slapped, cursed and threatened on the quest for better communication. I had dressed in drag with previous patients, when their level of consciousness was minimal. Singing and dancing at a level beyond all levels of propriety in patients' rooms, especially for people who have difficulty speaking, you can bring out the darndest speech!

I knew that, above all, helping activate the person's limbic system within the brain by communicating highly loaded emotional content - it would have good odds of prompting more communication. As I did when I wore dresses (and a prominent blonde/white mustache); when I made confetti from Post-It Notes and threw it over my OWN head when someone did well; when I organized a patient kazoo band to promote expiratory airflow;  - minimal advance notice and stealth were the key. Kickstarting the brain into communication, however reflexive. requires often a strong, unexpected stimulus.

The man in question had gone down for a deep sleep, following his morning treatment session. Deep sleep! No response to shaking the mattress slightly - so FWISHHHHHHHHHHHHHHHHH with some stretching and then blowing, four party balloons were inflated with the help of my well-trained lungs. Two were inserted in his canvas slip-ons, that rested in the seat of his wheelchair. The remaining two balloons were placed on his tray table. When I appeared during the later lunch hour, blowing up balloons for others within plan sight of his table,  - his laugh and smile were priceless!

Organic SLP:

Speech-language pathology (SLP) has become a well known commodity in the US human service economy. In most urban areas and many rural ones, there are speech-language pathologists serving the population from cradle to grave. Many SLP's are focused upon the needs of children, while scores more are specialists in the needs of adults. The need to communicate stays constant throughout the life span, though the aims of good communication differ with the different demands of human development - cradle to grave. The majority of SLP's are found within educational settings, though a growing number of professionals work within healthcare settings.With wholesale changes being brought to the field- through increasing demands by payors for accountability, and by the tightening of efficiency standards by employers looking to get the best return on investment, there are SLP's who have their clinical practices streamlined to keep the productivity high.  When more people are served, that furthers the profession and all those who benefit from our services. More SLP's work as well.

 But when quantity of service may jeopardize quality - and anecdotal reports from the field hint at such a degradation of service quality in some work settings - it is worthwhile to consider a service model that holds communication between person served and clinician uppermost; where the person served directs the care but is accountable for the outcomes achieved; where meeting the person's needs includes treating problems at the level of participation (involvement in life situations), instead of predominantly at the level of impairment (breakdown of bodily functions);and where the SLP uses all the tools available to her/him in the worksite. This participation-based approach to practicing clinical SLP we will call "organic SLP", to contrast it with impairment-based approaches to SLP that might be called "mechanistic SLP". Why is there a need for this approach to clinical treatment of communication problems?

* Mechanistic SLP makes us the 'question lady'. SLP is often known simply as answering questions from drill books, where human communication is a dynamic and versatile skill set that one does in all conditions. There is a need for skill development where persons served will use them, as early as possible. The person served should be a partner in all interventions whenever she/he has the capacity to do so, giving feedback often on the effectiveness of intervention. Communication thus becomes the game, the transaction that is demanded by real life - not the rigid stimulus-response routine of drill settings.

* Mechanistic SLP makes us too much like physical and occupational therapy. In a multidisciplinary treatment setting, most persons served identify mobility and self-care needs as the reason they are in "therapy". SLP may follow treatment sessions of the other professionals, at which time the person served may say "I'm tired from therapy!" or "I talk just fine" or "Are you going to ask me questions?".  Organic SLP approaches establish a positive, affirming relationship with the person served, so that treatment time is not solely a number of repetitions completed, or a % age of trials attempted. It is building a therapeutic relationship based on cooperation, built throughout the person's day and for which the SLP will provide high levels of customer service.

* Mechanistic SLP forces us to train persons to change behaviors at the component skill level - it is not real life. Clinicians who follow the evaluation with a roster of component skill exercises (e.g. sentence completions to improve formulation of thoughts; contrastive word pronunciations to improve speech clarity) - and that is all there is - face a person served who does not know how to turn success at drill, to success in real life where that skill is desired. There need be, from the time of evaluation, time given in each session to map the person's success at use of a component behavior - onto the real life setting where the behavior will be ultimately used.

*Mechanistic SLP does rely upon the latest advances in applied behavioral science, to help persons with communication (and swallowing) disorders keep the highest quality of life. Regardless of the high degree of reliability and validity for many of these treatments. SLP clinicians must finally keep it simple when it comes to training the person served towards independence. The component skills should be stepping stones over which the person served will move, to get to a level of competence with real life. The person served should hear from the SLP, something to the effect: "You're trying to get rid of me, so you can do this on your own. We will both know when that day has come. Until that day comes come, we will review often what we are doing and why. I will need your input about what we are doing, so that we can both be confident we have achieved YOUR goal". That is the mission of a practitioner of organic SLP.

What else can we ask of clinical SLP's, such as those who work with adults, that allow the persons served to touch real life in their training?The next post will provide some answers.