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. 

Shelter for the ingathering

I owe all of my understanding about this cultural wellspring, to a review of websites e.g. Chabad.org, through watching the PBS series "Sacred Journeys", and from recalling conversations over the decades with Jewish friends and persons served. Any lapses in the quality of the interpretation of the doctrines, their practice, or their being a metaphor for what a speech-language pathologist does - the fault is mine alone. My spiritual walk continues daily, and I welcome everyone's comments on how communication can do the "pretty wonderful" things it does for our better understanding.

The upshot of this blog post for readers: James Thurber and E.B. White once wrote "a man needs a den". A speech-language pathologist needs a SUKKAH.

As I am writing this, we are at the midpoint of the Jewish festival of Sukkot (translated from Hebrew as "booths"or "tabernacles"), which celebrates the protection given the Jewish people by God during their forty years' journey through the Arabian desert. Sukkot also is known as a harvest festival marking the end of the agricultural year, and then is termed the "Festival of the Ingathering". One hallmark of the festival for observant Jewish is the construction of a person's own sukkah (singular of sukkot) adjoining one's permanent home. The sukkah builder is to live within the structure during Sukkot as much as possible, blessing the structure daily and having meals in the sukkah with family and friends.

A sukkah's place in the harvest? It comes from the farmer traditionally living in such a structure, during the intense work schedule of bringing in the crops. Sharing a meal  in your sukkah is thus a time for celebration, and for blessings of the season to be dispersed amongst your loved ones.

I do not see any salient theological alignment, between what my colleagues do each day in their clinical work and what observant Jewish do in their sukkah. I do like still, the imagery of the sukkah as a protective enclosure about the person served. It may be a room with a door, with utter quiet provided from the outside world - though one of the university faculty stands opposite the mirror glass. It may be one corner of an elementary school playground,with room for student and teacher to stand alone. It may be a dual-occupancy SNF bedroom, with daytime TV dramas playing as mood music in the background. It may even be the hospice bed of a person slipping away, but the work of the speech-language pathologist evokes the spirit of the sukkah as protection from the world -  protection to grow and develop. As the newest Nobel literature laureate said it: "shelter from the storm".

Likewise, bringing in the harvest via use of the sukkah makes me think of the days of hard-fought success in meeting a person's treatment goals. The person and the speech-language pathologist spontaneously shine with the joy of accomplishment. Those readers of this blog who know of my fondness for incorporating gardening work into therapy, may know the pleasure of picking the first ripe tomato. Some of my colleagues have even helped their persons served, in picking the first punctuation mark they might use.

My everyday existence as a speech-language pathologist gives me the chance to create safe and fertile environments, and then to help extract the fruits of labor by the persons served. Sukkot is one symbolic stream that conveys the aims of the SLP in beautiful terms.

Spitting Raisinettes

They are fairly harmless candies, as candies go: a serving size is 10 pieces, with the total calories per serving size estimated at 41. And, as much as speech-language pathologists are dependent upon series of 10 repetitions of an activity - 41 calories may be the total calories you are required to exchange. But, SPITTING?!?!?

Why ask the person served to do this? This was a person with newly diagnosed amyotrophic lateral sclerosis (ALS), a degenerative disease that inevitably ravages the motor skills of the person and the person's support circle. Walking, toileting, sitting and standing, working, turning in bed, eating, talking, swallowing, coughing and breathing all are significantly challenged as the disease progresses. Why would you - the voices in my head screeched to me - insist that a person with ALS spit candy? Won't the physical effort be counterproductive to the patient's respiratory endurance, and degrade quality of life? Won't it hasten the person's functional decline?

It was a devilishly simple activity as designed: the person with ALS had a very comfortable, over- stuffed rocking chair. (S)he sat with head back, arms draped down the armrests and body in a neutral, seated midline position. Approximately three feet from the person's planted feet, a sea of white paper towels lay on the floor at the base of a television stand. I stood at the head of the person served, put a single Raisinette in her/his mouth, and directed the candy be spat onto the towel from where he sat. BLOW!!

It turned out that even persons with ALS could benefit from recent advances in exercise physiology and swallowing. Plowman et al. 's analysis of the effects of expiratory muscle strength training on swallow and cough function (Muscle Nerve. 2016 Jun; 54(1): 48–53), had suggested that persons in the early stages of ALS could experience some improvement in both domains. The admittedly silly activity presented to this person, at this moment in time, was an attempt to illustrate the mechanisms of a strong, functional cough - prior to starting use of a cough assist machine. 

"Sit back now - don't lean forward and blow while your waist is flexed. That's right: now, breathe in very deeply at the belly, so you feel your abdominal muscles are firm and a little distended. Here is the candy (placing it at the person's puckered lips); now - BLOW HARD! BLOW from your belly! BLOW BLOW! BLOW!!!"

And, golly gee willikers, this person DID BLOW the candy onto the towels on the floor, 8 out 10 times with maximum verbal and gestural cues. Abdominals, intercostals, sternocleidomastoid,....all well involved when the person had been struggling to get up the viscous frothy secretions that had been a continuous trouble. Even though the person served had initially reacted with shock when the candy FLEW THROUGH THE AIR, and landed on bare hardwood flooring just outside the barrier of paper towels - PICK THAT UP! was an exclamation heard more clearly than any other speech attempt of the past three months!

This Is the Voice (....)

She was pacing back in the wings off stage, before her presentation to the university lecture series was to begin. She was not on the university faculty; she had, though, completed her graduate classwork here and knew that her mentors would be scattered throughout the audience. She had begun to build her research specialty in voice disorders here; after there had been clinical discoveries too numerous to mention in the university speech clinic: hearing the initial sounds, words and sentences come out of a truck driver after a TEP prosthesis had been placed in his trach stoma; the delight of electronic squiggles when a cheerleader who needs to learn more resilient vocal habits, sings her "ah" as long as she can into the microphone; a middle-aged mother post CABG, works to erase the effects of her extubation granuloma; or even, the Parkinson patient reading aloud a bank of sentences loaded with junctures and with high front vowels.

Yes, she had been paying her dues over the years, in many clinical settings, to learn more and do more good for voices of all kinds. She knew though, that this lecture today might put her career as a voice scientist on the map - and open so many doors of opportunity. A new cohort of research subjects, perhaps. Maybe a collaboration with one of her former mentors. Guest lecturing in some classes at her alma mater?! So many opportunities may come about, because of this one appearance.

Now, it was almost time for her introduction, so - she chatted to herself in sotto voce, to hit the bullet points of her presentation, and hoped with articulated words that the projector for her PowerPoints will work correctly! Sooooooooooooooo embarrassed when she had given this talk in Iowa City, and when the projector was turned on - it smelled like one of those loose meat sandwiches popular in the upper Midwest. Let's hope, she said, that they pay close attention to the conclusions slide. That's my big finish.

So many thoughts flashing through her head now, like she is rifling through all the slides mentally, in rapid succession. Out in the audience, she sees through from the wings  to her former professors. There are her four favorites, sitting together in the center! She was forever grateful that her studies, and the patient prodding of her mentors, took her in the direction of voice science. It isn't the most lucrative of the specialties in speech-language pathology, nor is it the "sexiest", - but it is and it will be hers. Suddenly, she heard him....

Her head cocked as she heard - Carson Daly??

"This is The Voice Expert Extraordinare...." and she trod onstage to very appreciative applause.

Shall I attach myself?

I had been looking for some metaphors or images, that captured the depth of tragedy in which one finds her/himself with a dementia. It is the dissolution of self, in a most frightening form. Ultimately, the trope that arrived to my subconscious was the recurrence of macabre images from the Patrick Swayze/Demi Moore/Whoopi Goldberg film, GHOST.

When Tony Goldwyn, as Swayze ' s adversary, has his ectoplasmic self enveloped in black writhing, - I had found my images. It is terrifying to me; losing through the onset of dementia one's connection to the bigger world, the multiple perspectives, and the powers to reflect, reminisce and to rhapsodize. If I am writing this blog and am demented, then any attempt to make this topic understandable may be churned up and pulled into a vanishing point.

The late Robin Williams was found at autopsy to have shown signs of Lewy body dementia (LBD). The constellation of symptoms includes central, core, suggestive and supportive features - some similar to, and some very different than those seen in the most well known dementia: Alzheimer's disease. http://www.lbda.org provides resources that further outline the Lewy body dementia diagnostic criteria. One 2013 paper on LBD from the Mayo Clinic, described in the epidemiological literature*, cited its incidence as roughly one-fourth that for Parkinson disease. When Williams had discerned that his mental status had changed, and what the cause might have been, I can only imagine the terror and the pain he must have felt at knowing his creativity, his zest for life and his utter humanity were being dragged into fog.

Williams has had esteemed company, descending into that flat world of dementia. Charlton Heston, Univ. of Tennessee basketball coach Pat Summitt, Glen Campbell, Norman Rockwell, Ronald Reagan and E.B. White are only a few of the famous whose creative and productive lives have been spirited away. And, like other diseases and syndromes that affect the individual's ability to communicate, think and live independently, dementia brings gloom into the lives of the friends, family, support circles and wider world around the person afflicted. Those who know and care about the person with dementia - they are left to lament that the person they know - that person is leaving, or is gone.

It may be true - true, that the person with dementia is becoming someone not recognizable to their circles of support. The vestiges of the person that is remembered, should still compel her/his loved ones to keep near, and love the one they're with. The late Oliver Sacks made a particular point in his neurological case studies, of imbuing the persons he served with dignity - and giving them relentless respect. Whomever they had become at the time, Sacks saw that these persons were not that different than us and deserved our compassion.** They also deserve our connecting with them.

"Shall I attach myself to the man who sprays wax on the grass?" - this was a statement passed on from an actual patient with dementia, who said it to a colleague in a rehab hospital, who passed it along to me. YES, you should - that would be my answer. And we should attach to you.

* Savica R. et al, "Incidence of Dementia with Lewy Bodies and Parkinson Disease Dementia", JAMA Neurology, 2013, 3579.

**  for example, read Sacks' essay "The Lost Mariner", originally found in the 2/16/1984 NEW YORK REVIEW OF BOOKS, then collected in THE MAN WHO MISTOOK HIS WIFE FOR A HAT. New York: Touchstone/Simon and Schuster, 1998, 256 pp.