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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!


Attention! Therapy

3 Jun

I’ve been posting about specific things you could try in therapy for specific deficits, but I wanted to make a little disclaimer: It is very unlikely that you’ll encounter patients who just have issues in one of these areas. Patients post-stroke or BI are going to make ALL sorts of things going on, both mentally and physically. They might have any combination of deficits including but not limited to speech, expressive language, expressive language, pragmatics, memory, attention, fatigue  – you have to treat EVERYTHING…TOGETHER. You’re treating the whole person and all of their deficits. So when you’re reading these little blurbs about therapy ideas – try to imagine what it’d be like to treat expressive aphasia in someone who also has difficulty with selective attention, or treating someone who has comprehension issues and also memory deficits. We need to be very holistic and take SO MANY things into account.

That being said, after brain trauma many people have difficulty paying ATTENTION. They’re easily distracted, tangential, can’t filter, can’t focus on details. We learn about different kinds of attention and the types that I saw people having the most difficulty with were: selective attention, alternating attention, and a general complaint of boredom, fatigue, disinterest.

These are very typical issues post stroke or TBI. When I talk about selective attention I mean that the person can’t filter. They can’t focus on what I’m saying to them and NOT pay attention to the sounds in the hallway. Easily distracted by noises and visual information. They need training in what is relevant and not relevant information in reading and listening. When I talk about alternating attention, I mean that they have trouble bouncing between tasks. For example, right now I’m writing this blog and my mom is watching TV behind me. Every now and then I’ll stop and watch the TV or say something to my mom. When I’m done doing that I can come back to writing and I’m able to pick right back up where I’ve left off. In terms of boredom – you’ll often find patients will state that they feel foggy, they get zoned out, they just can’t focus.

What to do with this stuff? Well. Usually you want to start with removing distracting stimuli from the environment and then slowly incorporating it back into therapy. There are tasks such as APT which has levels to move up in attention capabilities. For selective attention, tasks that require someone to filter out information such as errors in spelling or text or locating something specific in the text like the word “the”. I always encourage my patients to approach this sort of task in steps. First scan and read the text. Then go back through and highlight what we’re looking for. Then check your work. If it’s an actual story they’re reading, it is very easy to get caught up in the actual story and not pay attention to the task at had. So giving them an opportunity to read it once for content is a way to reduce that phenomenon.

In alternating attention you may want to do a “switch” task. This is where you give the person three things to do and then make them switch between the tasks every few minutes. They’ll need to compensate by re-reading directions, marking places they’ve left off, and completing something before moving onto the next and not just abandoning a prompt in the middle. You might also give them something to do during a task, like count how many times they hear an overhead page or how many people walk by.

Don’t forget to TEACH how to do these tasks. Don’t just give someone three worksheets and then make them switch, or hand them an article and tell the to count the “the’s”. Train your patients for success. Scaffold. TREAT. You’re intervening!

When a patient tells me they can’t follow a conversation or get zoned out, I usually recommend we work on functional note taking. I had a patient who absolutely COULD NOT listen to her mother (haha) so we worked on taking notes during a conversation. Writing down the Who/What/When/Where/Why. I told her you don’t have to write down every single word that anyone says but at least try to jot down some simple key words so that (a) you’re actively listening and (b) you have a record of the conversation in case you can’t remember it later. Just like in school.

Like I’ve said before, this is not a be all end all of ideas, but just some things to consider or things to try. Every patient is going to be different and will require different supports.

NP: Brass in Pocket

Aphasia therapy

26 May


If you’re working with adults you’re PROBABLY working on aphasia. There are maaany types of aphasia. If you use the WAB, which there is a good case you will, then you will give your patients any one of eight aphasia diagnoses (Broca’s, Wernicke’s, Transcortical Motor, Transcortical Sensory, Global, Isolation, Conduction, Anomic). Most aphasias  be classified as fluent (receptive) or non-fluent (expressive). And there are other aphasias out there like primary progressive, alexia, agraphia etc. AND the way you classify aphasia will depend on your “theory” of aphasia.

I say all of this, but really you won’t see “pure” aphasias often – I would say many are mixed. You’ll see patients with a variety of difficulties that manifest themselves in all sorts of exciting ways.

AND QUITE FRANKLY – sometimes the diagnosis is SORTA irrelevant. To me – I’m not treating a diagnosis. I’m treating the issue. Just because someone has Broca’s aphasia doesn’t necessarily mean that the treatments typically used for Broca’s aphasia will work for this patient.

So what do you do with these patients – who may have difficulty speaking, understanding, reading, writing, spelling and a plethora of other troublesome word related tasks?

I’ll try to narrow it down a bit.

The patients I saw MOST OFTEN were having difficulty with word finding. I’ve had one patient with global aphasia and one patient with Wernicke’s. My externship had a very cool “Evidence Based Aphasia Clinic” which analyzed the aphasic characteristics of patients enrolled in the clinic, and then looked at EVIDENCE BASED protocols for treating aphasias. WHICH IS SO SMART. Everyone should do this. Not just with aphasia. With all things. One day I’d like to have at least one legit journal article printed off that explains why I do what I do with each kind of disorder that I focus on.

Back to what I was saying – What do we do with these patients? With a global aphasia you’ll likely be trying to find some kind of multi-modality communication system that will be consistently and appropriately utilized in the patient’s life. These are tough patients but you’ll find a way to communicate. One of my most favorite patients had global aphasia. She was the sassiest.

Wernicke’s? Wernicke’s aphasia is really cool. There is a Treatment for Wernicke’s Aphasia which works, but is extremely tedious and exhausting for EVERYBODY. Be sure to break up your sessions if you attempt it. The idea is you put out six photos (of 12 photos total) of everyday photos and first – hand the patient a card with a word on it. The patient matches the word to the picture. The patient then reads the word or verbally identifies the picture. The patient then repeats the word after you. Then you ask the patient to identify the picture with just a verbal cue. There is no scaffolding or cueing, but obviously for training purposes and for success purposes you’ll want to cue and prompt as necessary at the beginning. When I find the source for this I’ll share it – I’m not sure where I hid it. You can also do Response Elaboration Training, Cloze Procedures, Melodic Intonation Therapy, and I’m sure a number of other procedures.

And the biggie – word finding. This is going to change with each patient. I really enjoy category naming and teaching HOW to do this efficiently. I think often we say to a patient “Name all of the animals you can!” and then they have a hard time and we write down how many they got and then we tell them to name some other things. THIS IS NOT GOOD THERAPY.

Teach, don’t test, people.

So some ways we can deal with naming and word finding is to do semantic mapping tasks and semantic feature analysis. You can TEACH patients how to categorize by really thinking about how our brain works. How is our brain organized? Do we just have a jumble of animals in our brain all willy nilly? If someone asked YOU to name as many animals as you could what would you do? I often tell patients to subcategorize. Tell me animals, but first tell me farm animals, then zoo, pets, woodland, ocean, flying, etc. Tell me vegetables but envision yourself at the grocery store. And also consider – are you asking the patient to name CONCRETE items or ABSTRACT? Example time. Concrete: Animals. Abstract: Red things. Our brain is not organized by color.

Other tasks for word finding: synonym and antonym generation. And not just ONE word. Tell the patient to think of THREE antonyms. This gives you a good idea of where they are as far as what is difficult and what sorts of scaffolding is required. Can you give a patient a FIM score without really pushing them and figuring out what is hard? (No.)

Unscrambling tasks. Idiom defining.  Homonym explanation. Word defining. Seriously – ask a patient with a word finding disorder to define the word “tree”. Try that one. I really recommend the WALC books and Cognitive Reorganization if you work with aphasia often.

Now, I’m going to do the last edit of my thesis because I’ve been…not doing it.

NP: Anna Begins – Counting Crows

PS – if you Google just the word “WALC” you get this website. Lolz.


Inpatient questions

15 May


Q: I read in one of your posts that you didn’t like inpatient at all and that’s all that I’ll be doing. I was hoping you could offer some advice or words of encouragement?!

A: Don’t worry! Not everyone can love or hate everything. I have several friends who adore inpatient, acute therapy. Two of my friends have even taken jobs with acute care.

My beef: I don’t like constantly doing the same thing – which I sometimes feel like in inpatient. You don’t get to follow a patient through their progress – sometimes you may only see them for a very short period of time. On inpatient, I’m hesitant often because I’m uncomfortable – I haven’t spent a lot of time around sick people or hospitals. I don’t want to offend anyone, kill anyone, make anyone mad. And I have a hard time making my voice right – don’t wanna sound like I’m being condescending to grown people when I’m actually trying to sound sweet!

You will get comfy and that will help considerably. Just listen to your supervisor and copy her therapy moves and it will all work out. And honestly I’m doing better and better with inpatient everyday(but I still don’t want to do it!!)


New site!

24 Mar

I started my medical setting on Monday and it’s been pretty good! I’m doing only outpatient right now, which is good but I spend a lot of the day sitting (something I kind of abhor). Next week my supervisor starts floating so we’ll be running around between inpatient and outpatient which will keep me awake I’m thinking. I bought some ugly, but super comfy shoes from DSW – and if you’re going to be running around a hospital you may want something similar.

My clients are a mix of stroke and TBI, and we do a lot of memory, word finding/semantic activation, and executive functioning tasks. We currently have one dysphagia patient but we’ve got a few evals too. My site has access to FEES equipment which is cool, but I’m a little disappointed that I won’t get hands on MBS experience.

I think overall its going to be a great learning experience, my supervisor is incredibly intelligent and competent – she’s someone that I hope to be like when I’m a grown up. 🙂

NP: Drake – Headlines