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!