Should Old Arytenoids Be Subglot

Should Old Arytenoids Be Subglot
Like Pecs that Drape One's Knees; -
Then Let's Lift a Flagon of Stimulant
And demonstrate some physiologies!

For all the synapse'd parts of speech
For all the fricatives;
We'll bridge that communication gap
Avoid the ablatives.

If there's a deity above
S/He directs the cosmic cinema;
S/He wired the inner Dolby units;
They're called the cochlea

For all the full valleculae,
For pyriform plugged tight;
We'll drink a cup of lavage, YAY!
This frosty NYE night.

So - will you thus communicate
And swallow at your best?
Please make them such a '17 goal:
The gifts of cosmic largesse.

For old arytenoids, my dear;
For old arytenoidsssssss
We'll fix that diplophonia;
For old arytenoids!

Gotta Eat at Christmas

Most of my colleagues at the hospital are younger and have families, or are just barely out of college....so I volunteered to work Christmas. Man, is it ever dreary out there today!  Not horribly cold as I drove into the wet parking lot - about freezing - but the chill I feel to the bone. Mississippi Winter. Wicked! I've had - 20F Christmases, but they don't affect me like that winter on the cusp of phase change. It's warm on the floors anyway....

(Usually I am here before the rest of the rehab staff, but today - Xmas - it is even more important to get to my patients early. Seems like most of the PT's and OT's focus on getting through their list of patients, and whooshing home to the holiday festivities. Some even have to do the cooking! I try to avoid that feeling - opening the door "knock knock knock" of my first patient now - of being a human pinball, by "may I come in? Thank you...."  - by good time management, by staying in the moment and by assuring my patients that our therapy will be a good time!)

"Hello! It's Christmas morning, isn't it? My present was getting to see you early; and yes, I showered and shaved! And - what good timing, here comes the staff with breakfast now. Yay!....OK, here it is; may I help set it up for you?.....There we go; but before you start, let's make sure you are doing all the things you can always do to help yourself eat without a struggle..."

(She is here for treatment of her congestive heart failure and chronic obstructive pulmonary disease, with aspiration of food and liquid being a recurring challenge for her. Her videofluoroscopic swallowing evaluation was just yesterday, and showed she had a mild trend towards leaking things she swallowed from her throat, into her windpipe. Being here with her at breakfast is one component of helping her improve her skills. Swallowing treatment is today thought of as predominantly muscle retraining, but in the case of this Christmas breakfast, it is also a social cognitive act.)

"Those eggs look good, don't they? They are nice and warm....yes, you're swallowing well. Let's keep the good swallowing going. Remember what we practiced? After you've chewed each bite, swallow HARD! That's right! Swallow so you can feel your voice box bobbing UP and DOWN for each swallow. I can show you if you're doing it well, by resting my fingertip very lightly on the protruding part of your voice box - if you swallow hard enough, that part of your neck will rise above, then fall below the spot I mark with my fingertip. And, yes, there you go! You're moving that well when you swallow your breakfast!".

There were quite a few strong swallows after that sequence, but that was enough to illustrate what worked for this lady. I found the woman's nurse on the floor and reviewed the patient's progress, then wrote my note to describe the visit. Given the patient's chronic disease, and her tendency towards lying in bed when not exercising, teaching caregivers to grade the validity of the procedure seemed our best bet to help this woman meet her goals. Only ten more patients on this Christmas! Ho ho ho -and we steal into the mechanized Christmas morning, like Boxing Day Ninja shoppers off on a trial run.

It's a small virtual world after all; or, Deck the Lecture Halls!

(According to the weekly statistics of this blog's host, more views are coming from two areas outside the United States - France and Russia - than from around the great USA. No actionable intelligence here, folks!)

We wish you communication/
So free of tribulation/
No errs of articulation/
And no food in your teeth!//
Will you read any Luria?/
Or practice your Shaker? Ha!/
This time's a break from academia/
Park your endoscope by the wreath!//
Bonne voix à toi/ (Good voice to you)
Wherever you speak/
 n слышать разговоры (and hear conversations)/
For eight days a week!/
EVERY BODY SING!!
(Repeat chorus)











I have been gifted beyond measure by the response to this blog this year. May everyone, everywhere, soak up the au jus of the season in the bread of your choice - and keep communication pretty wonderful!

Walking and saying "gum"

This came to me while on a recent mall walk. The subfreezing weather in this area has made it wickedly tortuous to get outdoor exercise, so walking a few circuits of the local mall helps heat up the muscles, tendons and ligaments; it will stir the blood and unleash the peace. I doubt the majority of people who use physical therapy departments, colloquially termed the home of "physical torture", agree that what they do unleashes their peace. I feel it for myself during these walks.

The multiple engagements I must manage during the exercise period - dodging the shoppers and staff; avoiding the displays and distractions; maintaining the pace I want (only stop if you are going to hit someone/thing); foot plant begun with heel strike and step through, and great upright posture; all that - help me hear my inner voice. A lot of soul work gets done during those walks. It does help me unlock, feed and flex my mind. Gee, those PT's and I have a lot in common.

Even though our two professions are born of different mothers - APTA out of the wartime vocation of "Reconstruction Aides", originally all women; ASHA, largely male university clinicians serving disabled children; -  we each and together moved to meet acute needs of our consumers, in both the medical and educational spheres. Clinical discoveries and evolved standards of practice yielded programs of clinical and then, basic research; concurrently, educational standards for clinicians great and changed to meet the needs of consumers and the marketplace.

Above and beyond all the distinctions of the professions' growth, are the intertwining of movement and communication, of the motor act and the cognitive interaction. Our colleagues in physical therapy are cognizant of the contributions of play, of stress and of  daily need when moving and communicating. Stress is a distinctive quality of both the gym and the therapy room: I joke often that  some of my patients often begin to talk, when their bodies are stretched and contorted (OW! NO! =! $#%=£×_€=÷!!!).

I do admire our mutual interests and approaches; particularly, how movement and instrumental acts can engage the mind. I am still silently fretting when others assume I am a PT; that PT'S lead rehab departments predominantly; that PT took the lead at making the doctorate the terminal degree; or that we are joined at the hip for the Medicare B "therapy cap". Those dilemmas need not be owned by APTA. Time to just keep walking - and thinking.

The rest of the media story

You've seen in the previous post, that there are contemporary examples of persons with problems communicating, thinking or swallowing, portrayed in today's media and stirred into today's popular culture. With the current emphasis upon a "brand" and a "social media platform" being essential for the professional, one has to ask the questions, "Why aren't SLP'S featured more often in media and culture? How could  an SLP be a major character, or even THE main character in a play, film, novel or TV series?".

Then of course, I hear the blowback - as if it weren't all in my own mind: "Why would I want to be the star? Let me do my job and treat my students and patients, finish my documentation and go home". Real life tells us that our typical days are often not that heroic, and - we're not that sexy, not that charismatic, not that influential. Can an SLP be the hero?

Back in March 2016, this blog asked and answered the question "Who Exactly Are We?". It so happens that multiple sources affirm, an SLP is smart, industrious, courageous; that s/he takes the long view as well as the short; and that s/he listens and tends well the heart as well as the mind. Even though SLP's may influence most persons we encounter in the private, 1 to 1 world of the conversation, - the clinical encounter can often yield big, heroic outcomes! A person's striving to come fully into human existence, with communication, thinking and swallowing skills they need, is a journey that is often paved with tears, trauma, anxiety, sacrifice, ingenuity, humor and dogged, deliberate eyes-on-the-prize determination.

If you were to dramatize the clinical encounter, or any other events that surround a day in the life of the clincal encounter - would it be good TV? Good theatre or film drama?  It would be character driven, helping you know the principals involved as real, even flawed individuals who nonetheless are bound by a goal. Look at Henriette, Bauby's SLP in "The Diving Bell and the Butterfly". Look at Logue, King George's therapist and friend in "The King's Speech". They embody their mission - Logue is even fuller a character than Roi, as we get to know him more than just a professional. Building a story about the SLP, and how s/he can do things pivotal for helping people live fully, will not be fiction or fantasy or fluff.

One of my favorite canvas bags, out of all the canvas tote bags I have accumulated from meetings, etc., asks of the reader "I help people communicate. What's YOUR super power?".

I'm ready for my close-up, Dr. Van Riper

Through the years as an SLP, I have endured stark encounters with family and friends where they ask questions of what I do, often by saying " What do you do?" then they follow up after I describe a typical day, by saying, "REALLY! I never knew that speech therapists do this!". After that, I often make an observation that there have been very few opportunities for SLP's to toot the horn of this profession. After all, how often do you see an SLP represented in pop culture or by "the mainstream media"? And, if you have, could you believe your eyes and ears?!

For example, who can name a popular film in which SLP was prominently portrayed, apart than these films (attribution to the fine site "Speech Buddies" (speechbuddy.com) for this list)?

* The King's Speech
* Regarding Henry
* The Diving Bell and the Butterfly
* The Wild Child
* Sound and Fury
* Children of a Lesser God

There have also been TV series in variable formats (broadcast/cable/web), that portrayed persons with communication and cognition disorders, and the persons who interact with them. What programs can the reader recall other than the following?

* "Speechless" (the nonspeaking teenager has family and an aide translating his eyegaze communication)
* "Standardized" (fix my accent, please!)
* "MASH" (Winchester's affinity for helping persons who stutter)
*  "ER" (Cynthia Nixon cured of a severe aphasia in less than an hour)
* "Beavis and Butthead" (the boys talk about what they know, to learn more about articulation)

When it comes to the printed word, there are more options. You can consult the site GOODREADS, for lists of popular books on subjects related to communication and cognition disorders <https://www.goodreads.com/shelf/show/communication-disorders>.

Why is this important? There is so much competition for our eyes and ears, in learning about the world and making decisions about the meaning of life. I want the story of my profession told extremely well, and the day to day perceptions of a life that lights me up made so clear to the world, that the reader can see glimpses of how life's biggest questions may be answered. Maybe.

Welcome to SPEECH THERAPY! Example of an inservice outline on speech-language pathology for facility staff

I. Introduction (I am ST)

A. Name
B. Location
C. Education
D. Experience
E. Role @ my workplace

(Activity #1: introduce yourself to the person next to you....brief comments on the 'communication' required)

II. ST is a health professional that practices an "applied interdisciplinary behavioral science"

A. Applied -  benefiting everyday people
B. Interdisciplinary - coming out of the work of all these professions, and melded
C. Behavioral - people doing real things
D. Science - a systematic way of explaining the world

III. ST referrals are made to help persons with problems -

A. Swallowing (case example follows each alphanumeric item)
B. Thinking
1. Attention
2. Memory
3. Problem Solving
4. "Being An Adult" - Executive Function
C. Communicating
1. Speaking - Speech, Voice, Articulation
2. Listening - Receptive Language
3. Understanding - Speech Perception (hearing)

IV. What ST does, in summary:

A. Breakdown function to component parts - skilled activity
B. Train improvement of components in clinical (unnatural) settings
C. Retrain the whole activities in natural settings

V. What YOU can do to help persons having problems with these skills

A. Offer assistance to the persons through use of compensations
(Activity #2: Demonstrate compensations used for persons having problems swallowing)
B. Identify for ST those persons for whom compensations are used; determine the need for additional evaluation.
C. Assist ST in helping the person improve skills as needed, through use of compensations and a home exercise program (as needed)
(Activity #3: Home Exercise program example - kazoo blowing for increased exhalation strength)

VI. Questions?

VII. Thank you!

Help Them Meet their Goals

Now it was Friday at the 2016 ASHA Convention, and after an early morning meeting and my quick shopping trip through the Exhibit Hall, - the meetings continued. So far, this Convention has shown the attendee that, there's value added to therapy that asks you to do natural things; that the diversity of the membership need be nurtured; that the ability to map interactions help you interact for a desired future; and that persons can be successful at interrupting reflex pathways to modulate cough. What worlds were there to conquer still, today?? After topping the Rocky Steps last night, what? Me, worry?

Malnutrition - we have known it to be the riddle in clinical settings that is not easily solved by dysphagia protocols. Not everything the person served needs, is solved by the traditional eval and treat approach. Shune and Morano - Villhauer showed how the twain of malnutrition and dysphagia may meet, and gave participants tools for working with these complex cases as real people - so that the age-related phenomena of malnutrition might be modulated by an interdisciplinary team.

Weinstock-Guttman, Chiaravalloti and Tjaden provided insights into the 2013 revised diagnostic criteria for multiple sclerosis, the more effective treatments for cognitive impairment, and recent developments for treatment of motor speech impairment. The complications of MS are numerous, and the challenge of bringing successful outcomes to these persons served - is a challenge of getting to know one person at a time, very well. A resource for doing so is illustrated in the following:

I was very pleased to hear the paper by Devanga and Hengst, from further on down the road at UI/ Urbana - Champaign - where "collaborative referencing" after aphasia was targeted by an experimental treatment. With the person with aphasia being both the person directing, and then one following directions, data emerging suggests that the procedure may significantly improve expressive communication in these persons served.

My 2016 Convention closed with "Conversations on Death and Dying", Carrico Mann. Her perspective on end of life issues, and how professionals in speech-language pathology may engage with these persons served, in the stages of preactive and active dying, and with considerations for different cultures, and the skill set for comforting a person served and their circles of support; the handout provided gives a good beginning list of print and web-based resources in palliative and hospice care.

There was a last swim at the motel after sessions ended, with an early flight home on Saturday. Given the weight of the sessions I attended, it could be said that the sun was coming down on a world view by speech-language pathology - alternatively, the sun may be coming up on another.

Out of the Beehive

Salon H at the Downtown Philadelphia Marriott, and it's five minutes and counting until the educational portion of the 2016 ASHA Convention is on the air! Hovering over attendees is a large circular chandelier, glowing with the anticipation felt by all in the room, ready to lift off .

A confession to readers: I do not attend the convention's opening session.   The 2014 opening session at Orlando, my only attempt at team spirit since the format change,  was a massive beehive with few opportunities to soak up why we were there - other than the transcendent keynote address by the late Maya Angelou. We've lost 90 minutes on the first day, that had once been open for education. Yes, I said it.

 Finally: to start the day, LaGorio, Crary and Carnaby provided case presentations based upon the McNeill Dysphagia Treatment (MDTP). We were reassured continually through the seminar, that this presentation was NOT to be a "how-to" treatment of MDTP. That was quite OK with participants, as the data shows that outcomes following MDTP were superior to training the person served in compensations, or through compensations plus neuromuscular electrical stimulation.

Encouraging to see that in this treatment approach, the treatment for impaired swallowing is a high frequency of swallowing. When LaGorio reported that she has not used most of her traditional dysphagia treatment 'bag of tricks' in the last 10 years, the sighs of relief could have pulled paint off the wall. Carnaby echoed this statement at the final 15 minutes, remarking that the intensity and frequency of the programawww is critical for changing the physiology of the swallow, not solely the compensations that momentarily protect against aspiration. MDTP may be seen then as an activity - based treatment of swallowing, for which you as the clinician may obtain greater buy-in. We like that!

Though this is not a certain CNN travel show, a meal interlude is in order. ASHA Convention organizers are forever in my debt, for offering each year a catered lunch option to pre-order then pick up at the exhibit hall with a ticket. The quinoa salad on Thursday,  and then kale salad on Friday, were accompanied by a gluten free, vegan dessert that filled you up without bringing on the pm calorie crash. No fighting for time and space in area restaurants, and no paying convention center prices!

Maldonado, post-lunch, was not as fortunate with interest in his subject (males in the profession), as was the MDTP group: 2 attendees! I was the male. His study, borne of grounded theory, showed that the pay levels, the rigidity of gender roles holding back many men from becoming a speech-language pathologist, and the perceived truncating of career advance opportunities - all continue, as they have since the 1980's, to keep the prevalence of men in the professions at or near 4% of the total ASHA membership. The answer, my colleague, is blowing through the corridors.

Archer reported on the contributions of cognitive ethnography to treating cognitive - communicative disorders. Relevant to qualitative study of training improved interaction, were  the insights that cognitive reserve is distributed among agents in the community of persons served; and that an ethnography constructed of conversation analyses of the person helps map the road to cognitive- communicative 'recovery'. Blog readers will easily figure out - We like this too!

Palmer and colleagues ended the lecture sessions for the first day, with a review of irritable larynx syndrome with chronic cough. The constellation of behavioral treatments in the SLP's armamentaria  can be built upon  with technology eg endoscopy, but it is still the skill and humanity of the individual clinician, in this instance, that most often brings real relief to these persons served. Suppress the cough, gain increased laryngeal control,  and learn to think critically about coughing itself.

Thursday night was a treat, thanks to the sponsorship of a trolley tour of downtown Philly by Lingraphica, a leading vendor of AAC systems. Don't worry; the trolley cars were enclosed and comfy. We got gratis cheesesteaks, soda, beer and wine. We saw the performing arts district, the financial district, Old City (including a Liberty Bell peekaboo), Penn ' s Landing, and the Museum of Art with their famous "Rocky Steps". Wow - I made it!

Staying at a motel in North Wales PA, 25 miles NNW of the Convention Center, allowed some quiet after a day of high focus, seeing the local culture - and a fun side trip to Valley Forge prior to convention's start. Bedtime was welcome Thursday night. But Friday would come early.

Why Ethnography?

(Those blog readers needing additional grounding in the methods described and how they impact clinical speech-language pathology, can read Damico and Simmons - Mackie 's tutorial on qualitative research in a 2003 issue of the AMERICAN JOURNAL OF SPEECH -LANGUAGE PATHOLOGY.)

They called her "the Doctor", and there is a difference of opinion about why that was so. "She looks like a doctor", was the rationale often heard among persons she met at work.  She was NOT a Doctor! Her hair was greying over her ears, and she carried herself with a quiet, distinguished air. She also wore a lab coat, though she did not need the mark of the ancient guild - she had said she needed the "Captain Kangaroo" pockets in the coat to carry her stuff! She may need washable markers, and a penlight, and tongue depressors, and an applesauce container, And she had made a point, when her job started at the building, to meet and greet everyone who lived within and NOT just people on the clinical caseload. She had a method to her madness; really!

For example, when there was a new referral for service she might interact with the newest person served in a group setting (eating a meal, or participating in a leisure activity). Persons directly AND INDIRECTLY connected to the person served, often would volunteer their observations during or after the visit. Those observers may also, at times, help interpret the experience for the person served. Some of these observers are followers in the culture, but others are leaders - leaders on the playground, in the gardening session, or at weekly worship services. The Doctor learned the processes and agents that made the culture work: who had nominal power that made the culture run, and who in fact wielded actual power and influence. Some of the movers and shakers (who controlled the conversation at the big table at lunch; who could get you an extra dessert; who had been in therapy previously and could help the newest person served, adjust) - they might have insights into what the person needs, and might be open to an occasional interview.

The Doctor made certain that, from the beginning of her tenure at the facility, that most people knew who she was and what she did. It made clinical encounters in a group less anxious for the members (Who's that woman? What is she doing here? Is she going to talk to ME? You talking to me??), and made the culture - the community - more a circle of friends and supporters for the new person served. As the Doctor used to say, "One day you'll be rid of me; that is when you must rely on the support of all you spend time with here each day". It was the Doctor's intent to sketch in as clear detail as possible, that skilled intervention to help persons increase their function for cognition, communication and swallowing - it is finite, and the degree of change that comes about through clinical intervention can be sustained to some degree, by the processes of the culture.

The Doctor composed her ethnography of her work site, during the first month of her tenure at that facility. At the end of the process, there were explicit and implicit rules known. Hierarchies of control for persons, and for resources were more easily understood. How would a successful therapy outcome dovetail with the goals of the culture? She could predict that outcome much more easily now. Over the years, she knows that the study of her work 'culture' will have to be re examined, revised and rejudged for its validity. That is pittance little work on top of her clinical responsibilities, for it - the ethnography - can be a major road map to superior clinical outcomes.

is "is", 'IS'??

There is about you a constant level of background chatter as the day starts. When you wake and look about, everyone that is talking seems hard to understand; when you attempt to speak to those gathered about your bed - "Ah, good morning!" - they look curious, then quizzical then - forceful, accusatory then - condescending. "She just doesn't understand". "We'll keep her safe but  - let's move on".

You might think she had suffered  a stroke or some other disruption of consciousness; but, no - it was the aftermath of a political campaign. She saw the world as "A", while her interrogators were "B" folk.

And, like most people who base their quality of life and - their livelihood, on fluid and robust communication, misunderstandings and BREAKDOWNS in communication, like the political morass of the age, impassion her - and me - to give the best advice and guidance for conversational REPAIR. Communication is pretty wonderful, because we realize - in the nick of time - its habitual breakdown poses significant DANGER to the health of our social structures. What to do, as you maneuver the body social and politic in these times?

Speech-language pathologists often help the people we serve measure their meandering for conversation, then develop and implement successful strategies that approach straight lines of sharing information. Some of the clinical strategies can be applied to conversations the general public is having at this historical crossroads. In general, the strategies can include:

* Don't make noise and don't encourage any noise. Though you and your conversation partner may continue to harbor strong emotions about your side, communicate with just enough emotion through the clarity of your arguments, and not via the pH level of your insults.

*Approach the conversation by conveying in words and actions, - I am here to share. I am here to understand. I am not here to fight . Your sharing that message may encourage the partner to adopt the same position. If either you or the partner approaches  the invitation with a high level of emotion, you will have to repeat your conditions (Earthling, I come in peace);

*You and your partner may have to repeat, as often as necessary, those initial setting of conditions before the sharing of ideas can begin. If either of you does not agree to conditions, cut the connection until the ground rules can be set. I don't think we are ready for this discussion, you might say. But once you and the partner are ready to address an issue -

* Trust, but clarify. Stop and think often as positions are shared. Confirm your understanding of what has been said.  Periodically agree that the  initial conditions are in force, then recalibrate them as needed. Do occasional summaries of the discussion and confirm understanding between both parties. The goal therefore, is not to win but to understand. Understanding trumps warfare. Communication feeds more interaction. Interaction growing leads to - what's next.

My ethnography

 This is NOT the culture and heritage for most of us. But with the current political campaign we have endured over the past year in the United States (people around the globe are looking at this blog - AMAZING), we're often forced or cajoled or intimidated to choose sides on the important policy and social issues facing the US, after the election on November 8. Bold lines of distinction can be hastily drawn.

 I feel justified when I say that we tend to duck down when there is cultural confrontation. We want to avoid drawing a lot of attention to ourselves, though we want to see it all. We are fascinated by the car wreck occurring, - can't look away - but we know that if we get sucked into the confrontation, we will perhaps, - change??

That's how it is with living in a culture - loosely defined as the beliefs of a particular group. Whether you are a leader of a culture, or one of the more prevalent followers of the cultural standards, it is good to know what is what; whose palms need be greased, and where do you enter to start your acculturation. "My hair!"

Speech-language pathologists, no matter what their work setting, are often in a culture but not of the culture. You often benefit from knowing the culture's most subtle workings, so you can serve persons who come to you. To better serve those persons, it often helps to begin your work by knowing how the person's cultures help or hurt the outcome they desire from treatment.  In a new job setting or a new job circumstance, to answer those questions about the person's cultures -   write an ethnography.

An ethnography is a documentation of the culture: how it is constructed, how it works and the implications of its existence.  Ethnography is a skill set out of anthropology, requiring the SLP to apply all the powers of observation she/he has. Given the penchant of SLP's to evaluate the effects of interventions, writing an ethnography might portray the culture at its natural, or resting or baseline state. 

The writings may include as evidence, data from the culture's members, in the form of interviews, surveys,  photos, video and other illustrative data (news articles , manufactured products, social media posts) that tell the culture's story. With the intervention in play, the SLP can then re-examine the variables checked at as few he. Why, though, - why pile on the SLP so much extra work to - not only help the person served improve function, but also paint the big picture of what and where and how the culture influences the outcome?

For my ancestors

(Blogger's note: this material was previously been submitted in different form, to the STEP program of the American Speech-Language-Hearing Association).

We have celebrated the end of the earth's "productive" season for agriculture, and now memories of those persons dear to us who have died come to bloom again. I find peace in my life now more than ever from ritual and discipline, though aberrations and outliers from the routine I embrace and term them instruments of "Alzheimer's prevention". I think the cycles of gardening that have helped me attune my own psychic rhythms to the seasons, also help me appreciate the time of year and the need for respect shown our departed elders. Not only are the departed from my family, but also from my work and community life.

According to his Facebook account, his 79th birthday would have been yesterday. He was not, to my mind, a person who beckoned attention his way but who on receipt, ate it up like it was fresh hot fried chicken. He embodied for and expressed from his students rigor, professionalism, good cheer and clear thinking. When he undertook advising first the pre-medical students, then all those entering health careers at our University, we all knew that the pre-med kids were getting a very big bargain with him.

He was first my clinic supervisor when I entered the world of CSD as a client - my long time  stuttering problem had waxed and waned over the years of adolescence, but suddenly became a moose sitting in my traffic lane - as my vehicle was pointed towards a future as a teacher. At the end of my summer session after my junior year of university, the growth in my speech fluency allowed me to refocus my career plans to include - speech-language pathology!!

He was rightly skeptical that a liberal arts student who had been focusing on analysis of novels and plays, would easily flip to swim well in the world of whole-language reading and phonological processes. He accompanied me to the 1974 ASHA Convention in Las Vegas as coach and interpreter, to guide me to sessions that may help answer my question: What is therapy all about? He gave no more than a chuckle to my comment that, at 3 a.m. prior to the last day of meetings, I had respectfully declined an offer to "party" from the back of a mustard yellow Mustang on the Strip. "I have to get up at 6 - Convention!", I said. He put the topper on my pre-service training, even before my first undergraduate classes in CSD had begun (I had my fourth year to complete enough classes for a minor, and enter the master's program the following Fall). He taught me, at age 21, to tie a Windsor knot to prepare for Convention meetings.

He cultivated discipline and clarity in our clinical work. As our clinical supervisor he was a model of joy, method, and requiring big time investment of the client and supports in the treatment plan. He taught you  that you could accomplish big things. All this from a deceptively quiet guy.

Thank you, Dr. Hugh Bateman.

Sorry - I was eating a chocolate bar - BOO! COUGH!

We just survived National Chocolate Day, a gift to us from the National Confectioners Association. It's so coincidental that Halloween is just around the corner, because that day is often a showcase for United States chocolate consumption (9th highest in the world, at 9.5 lbs per person per year). We lag behind such chocolate noshers as Switzerland (highest global per capita consumption @ 19.8 lbs/person/year) and Australia (7th highest; 10.8 lbs).

Chocolates we will pick up in the grocery checkout line, or we will stop by the specialty store kiosk at the mall, - or perhaps a charity has representatives standing at an intersection near your home, and so you  throw some coins into their bucket and you get a chocolate bar in return....or the kid has just returned from her Halloween candy quest through the neighborhoods, and you feel obliged to inspect the kisses and the mini-bars for poison, popping one or three or twelve into your mouth! Regardless of the source of our great fantasy food, it is easily found and thoroughly enjoyed across ages, genders, cultures and diets. But slow down - you're moving too fast!

"This child is choking to death", said the Doc. When you are young and content to eat a hot dog at the ball park, - but then the adults pull you into the middle of their consternations, - what is a girl like Karin Kinsella to do? Distracted eating, according to the Harvard Health blog(1), not only taxes a person's attention and memory capacity during food/liquid consumption but also limits enjoyment of the meal and the body's ability to digest and use the food as intended. We all do it! Packing a snack, a meal or a quaffing of the beverage of choice into a few minutes here, a few there amidst our busy days - we learn to expect this routine as we look over our personal life, our work life, our leisure existence and our family/circle existence. We eat and drink in chaos, and sometimes at a cost. We eat while driving, we eat while watching TV, while in rapid-fire conversations and engulfed in loud, pounding music. Our swallowing systems have functional reserves that usually allow us the latitude to eat/drink in all those circumstances, and even - as has been described elsewhere - upside down.

For those persons who have had reserves for swallowing function decline and erode, those chocolate noshes may be easy as pie, or as challenging as chewing concrete. Do you struggle to hold the candy in a pincer grasp? Are lips grasping at the bite to keep it within the cavity? Are there enough teeth to grind and pulverize the creamy chunk into a viscous goo for the swallow trigger?? The list of things that can go wrong with CHOCOLATE EATING, is further amplified by everything else happening around the person. TV on; numerous persons attempting to take some of the chocolate for their own; side conversations floating in the air; the anticipation of some activity - bed, if not more activity - following the meal; those SLP's that work in such settings, irregardless of age or physical etiology - they have some work to do.

Control the noise, so that the person served can get reacquainted with their sensory and motor systems through training or compensating to make chocolate eating great again.  The person served can be re acclimated to the natural setting, when both individual and environmental controls are in place to make the eating experience pleasurable. It is a clear road map, to help the person feeding her/himself to enjoy what was National Chocolate Day, anticipate Diwali and brace for Halloween.

"HOW MANY left on base?? Sheesh, give me another Snickers!"

(1) LeWine, Howard, MD, "Distracted Eating May Lead to Weight Gain", Harvard Health Blog. Cambridge MA: Posted 3/29/13.

National Physical Therapy Month: it's relatively painless

A tip of the hat to my colleagues in physical therapy: October has been held up as 'National Physical Therapy Month', during which time the physical therapy profession has engaged the public with information on its mission and its value. This year's campaign by the American Physical Therapy Association  (APTA) stresses the choices consumers of services have for pain management; namely, choosing PT as an alternative to opioid reliance and/or dependence when living with pain. #ChoosePT is the designation of the campaign, designed to educate and encourage the person in need of pain management, and her/his circle of support.

The site http://www.moveforwardpt.com/choose-physical-therapy-over-opioids-for-pain-management-choosept will give the interested reader decision points and options for coordinating the process of pain management with a physician, PT or other involved health care professional. It's been my experience that a proactive plan for pain management can hardly ever be too "pro-"; that is, it will hardly ever occur too early, for the recovery process of the individual affected. Pain,whatever its etiology, can be a catalyst for the erosion of a person's quality of life, eating away at the physical, psychological and emotional reserves of the person involved - if not thoughtfully managed.

Other health professionals contribute to the management of pain in persons we serve. Crawford et al. (2016) indicated in "a systematic review and meta-analysis of randomized controlled trials", that massage therapy is weakly recommended for reducing pain, and for increasing mood and quality of life, when compared to no treatment (1). Scholten-Peeters et al. (2013) reported that chiropractic manipulation yielded a significant effect on pain relief in adults with musculoskeletal complaints (2).

In the case of the person who has physical and cognitive/communicative needs after suffering an impairment of bodily function, - when the pain management plan is incomplete or not adaptable to changing circumstances, pain-related alterations in cognition can further depress the individual's quality of life. For the speech-language pathologist treating a person for whom pain has been "socked in", being part of the pain management plan is essential. The clinical SLP who is involved with patients having frequent pain needs, should consult reviews of behavioral approaches to pain e.g. Songer (2005) (3) for insight into approaches that may help your patient.

With my person served demonstrating significant pain,  - perhaps a PT or OT session had just been completed prior to my appearance. Prevent this scheduling 'oops' whenever possible. If pain is the sole concern, then focus on being time efficient. Keep the mood light. Reinforce points you stressed vocally with a written note, left with the person at the session's end. Note any effects of positioning, behavioral or medical intervention for pain, along with the person's pain rating. Review your experiences with the person in pain with the treatment team periodically, and adapt your treatment approaches as the person's need for pain management changes. Embrace the target: be part of the solution to pain as a barrier.

(1) Crawford, Cindy, et al., "The Impact of Massage Therapy on Function in Pain Populations—A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population", Pain Medicine, 17(7), July 2016, 1353-75. 
(2) Scholten-Peeters, Gwendolijne GM et al., "Is Manipulative Therapy More Effective than Sham Manipulation in Adults?. A Systematic Review and Meta-Analysis, "BioMed Central, 21(34), 2 October 2013. 
(3) Songer, Douglas, "Psychotherapeutic Approaches in the Treatment of Pain", Psychiatry MMC, 2(5), May 2005, 19-24.

Growing CSD students

I have yet to see after 30+ years of clinical practice,  a clinical encounter within the realm of speech-language pathology (SLP) whose outcome had not been heightened by the interactions of humans with plants. Edwards (2016) in the ASHA LEADER(1), likewise gave high marks to the inclusion of gardening work, with traditional operations of a university speech and language clinic. The author expressed in this article some surprise at the degree of buy-in for gardening activities by faculty, staff, students and clients.  To paraphrase the Tom Hanks character's speech in a popular baseball film: there are no surprises in gardening! There should be no surprise, that is - that clients of all ages do and will be positively affected by it.

There are distinct advantages for all parties to participate in a garden program: using a natural environment for skill practice; adapting the gamut of typical activities to all physical and cognitive/communicative skill levels, and optimizing participation of clients to meet concrete goals, with rewards ranging from social and tangible praise to sharing consumption of the harvest. Edwards reported that problems with the physical access of clinic clients to gardening activities, as well as the availability of persons available to tend and supervise garden activities, are some of the major impediments to making a university clinic gardening program thrive. Careful planning and coordination of a clinic gardening program are major keys to the program's success.

Having a garden on campus for the pre-service education of future SLP's thus may provide communication sciences and disorders programs with a versatile "toy box". Student clinicians at various skill levels, for conducting evaluation and treatment of communication/swallowing disorders, may utilize a garden program to fulfill program goals in the areas of speech, language, hearing, fluency, voice, cognition, and - yes, even swallowing disorders. The unique activities presented by gardening for clinic clients during an academic year, would appear to attract a wide variety of clients and clinicians. Yet, big barriers to launching a gardening program as part of an SLP training program remain.

1. Physical Access: How easily can the persons served interact and engage with the plants in the garden??
2. Budget Lines: How does a university clinic fund start up and operational costs?
3. Garden Management: Who - between treatment sessions, and between academic terms, - takes responsibility for general management of the garden environment?
4. Recruitment: Who will want to work in dirt? With pests? While carrying tools and implements? For most of an academic term? With clients who get messy, and who may need physical assistance?
5. Garden Security: How is the gardening environment kept protected from the curious,who may not have the best interests of the garden program at heart?

At present there are 13 university training programs in my state, for persons studying towards the master's degree in speech-language pathology. In another year, I hope to have helped each of them incorporate gardening activities into their training programs. Keep watching this space for details.

(1). Edwards, Collette, "Growing and Harvesting Success: An On-Campus Garden Helps University Clinic Clients Learn to Generalize their New Skills", ASHA LEADER, v. 21 (May 2016), 38-39.