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The Visual Swallow Study

15 Oct

As previously stated, I’ve been doing a LOT of visual swallow studies. Mostly with group home residents who have developmental disabilities.

What am I doing exactly? I don’t have access to FEES or MBS, so I’m basically doing a bedside evaluation. The outcome of which is USUALLY: refer for a FEES or MBS, refer for skilled speech language services to train in safe swallow strategies, diet modification, meal time modification, or no changes!

So here’s how it goes:

1. I generally start with an oral motor examination. This tends to be slightly difficult because this population of older adults (usually 50-60ish) with developmental disabilities didn’t HAVE access to early intervention – and in some cases any intervention at all. So the cognitive skills, the ability to follow simple one step directions with verbal, visual, and tactile cues: not really present. Sometimes they are able to imitate me and in some cases they are able to follow directions (but not always – I don’t count on it.) So at the least I try to get in and check out dentition and structure (size of tongue in relation to oral cavity, lip seal, tone etc.) It’s important to note whether the patient is able to follow directions because this is going to be a major factor in whether I think they’d benefit from skilled speech therapy services focusing on compensatory manuevers.

2. I check out language skills. As with the cognition – a lot of my patients don’t have strong receptive or expressive language. I want to be able to say in my report what their language is like, how do they communicate.

3. I chat with caregivers while the patient is eating. I want to know: Where do they eat their meals? What diet are they on? What kind of supervision do they receive? Have they had previous swallow studies? Previous swallow difficulties? Do they have special tools for eating? (Divided plate, cutlery with handles) Do they avoid giving this person any types of food and why? Is how they’re eating today comparable to their normal habits? What kind of prompts are given to this person and what is their response? Have they seen any signs/symptoms of aspirations/penetration?

Also in the group homes in Delaware the patients are given a “Choking Risk Assessment” – I like to get a copy of that report as well as their most recent nursing assessment. Often times what the nursing assessment says about the person’s diet is different than what the caregivers report and that is important to know.

4. While I’m chatting I’m also checking out the person eating their lunch. I note all foods and drinks trialed and response. Rate, signs/symptoms of asp/penetration, time to initiate swallow, prompts required and response to prompts, peri and inter oral residues, laryngeal excursion. Do they talk while they eat? How is their voice? How is respiration? Rotary chew? Tongue thrust/delayed swallow pattern?

5. Then if I see anything that concerns me, I try out some strategies. If they have the cognition I may try a superglottic swallow, chin tuck, head turn – whatever I think would work best. I might try to encourage small sips, small bites, alternating bites and sips. Here I also check comprehension – do they have a concept of “small” or “slow”? Or are we just saying “Small bites!” over and over to no avail? I’ll try out some different prompting strategies and see how they respond. I may try breaking their meals into smaller portions or bites.

6. I summarize my findings and discuss with caregiver. Generally I provide them with an outline of the National Dysphagia Diet (circling the one I recommend), a list of typical swallow function in older adults,  and I may give them something to try out like a visual pacer they could laminate.

7. I write!

Now, I have about an hour for an actual evaluation and it pretty much takes that entire time. Honestly the most common dysphagia I see with this population is RAPID stuffing of food and gulping of liquids. Very impulsive and highly motivated by food. I have never in my life seen this before so the first time it was a REAL SHOCKER. I try to avoid diet modifications because I think diet has a major effect on quality of life, but I will do it for the safety of the person. Usually with the rapid stuffing I recommended 1:1 supervision, with consistent prompts to slow, wait, stop, chew, etc. I also recommend that meals be presented in portions – just a little at a time! Liquids included! They don’t need their entire meal at once. And often cutting food into small bite sized pieces helps slow them down a little.

I’m really enjoying these evaluations so if you have any questions please feel free to ask! Or give me ideas! I love ideas!

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Breakin’ the Law

4 Sep

Something that has been on my mind lately is following the rules.

As an undergrad when I was first introduced to testing protocol it was hammered into our heads, “DO WHAT THE MANUAL SAYS.” No extra prompting, no coloring outside the lines, just do what you are supposed to do or the test is invalidated and you suck.

And I’m okay with this, but only in the case of eligibility. You give a test to determine eligibility for services, then you want the results to be reliable and valid. So follow the rules.

However, tests have a lot of purposes. You can use a test to probe a specific area of concern, to screen, to compare to previous results. As an SLP I am certainly curious about my clients’ problem areas and I want them to qualify for skilled services. But I also want to know how they perform with prompts and cues. I want to alter protocols to explore my clients’ strengths and weaknesses. I want to make goals that truly suit their needs. And in these cases I say, go ahead and break the rules! (Do it, I dare you.)

The same goes for specific therapy techniques. There are a lot of programs out there that you must attend the workshop, obtain a certification, and follow the rules! This program won’t work unless you follow those rules! And you know what – some of these programs genuinely work, have excellent evidence backing them up, and are truly wonderful for our clients.

But by suggesting that “the rules” work for every single client is unrealistic. Our clients are individuals and between them, their needs are so different. I say take those rules and stick with the main basis and the main theory, but alter them as needed! I want my clients to experience success and I’ll change up things if I determine that it is appropriate to do so.

You’ll often hear “You aren’t doing X-program if you aren’t following the rules outlined by said program.” And to that I say, “So be it.” I don’t particularly care if I’m following the rules so long as I’m making therapy beneficial to my client. Obviously you should NOT run around saying you’re a provider of a specific kind of therapy or program if you haven’t actually been certified (that’s a quick way to get yourself sued), but if you have and you want to make some changes I think you should be able to. I understand and respect companies’ desire to charge money to certify and educate SLPs in their specific program, but I also think it is a little backwards that companies have resources and ideas that WORK that aren’t open sourced to all clinicians. We should all have equal access to important research and programs.

As CSD professionals we are lucky enough to have an incredible amount of resources at hand. Tests and tools and strategies that are becoming more and more evidence based. With the #slpeeps on Twitter we can discuss what we like and don’t like, and explore what really works. It is really wonderful. I think we should use each other’s skills, expertise, and ideas for adapting protocols even more than we do now, and really encourage the concept of open-source therapy. Share the adaptations that work, so we can all help our clients benefit!

NP: The Cure – Pictures of You

I just have so much useful info to share this morning

28 Sep

Medicare Part B Supervision Requirements for Videostroboscopy and Nasopharyngoscopy Procedures Rescinded Effective October 1, 2011

Effective October 1, 2011, the Centers for Medicare & Medicaid Services (CMS) is rescinding the requirement that became effective January 1, 2011, that supervision of the videostroboscopy (CPT 31579) and nasopharyngoscopy (CPT 92511) procedures required a physician to be in the room. In March 2011, representatives from ASHA and the American Academy of Otolaryngology – Head and Neck Surgery met with CMS officials. Additionally, ASHA members protested the need for such supervision to members of Congress. As a result, the CMS Administrator issued a letter in June 2011, acknowledging that “while physicians perform these diagnostic procedures, speech pathologists also perform these procedures to evaluate and treat a patient’s functional/use problems.” The letter removed all supervision levels previously assigned to the procedures, effective October 1.

ASHA, in conjunction with Special Interest Group 3: Voice and Voice Disorders, has developed Frequently Asked Questions to clarify billing and supervision issues related to the CMS decision.

For additional information, please contact reimbursement@asha.org.

SO basically: we can look at the vocal folds and such without supervision now. Cool.