Today I was just observing clients. The first was in their 80s, who had had an extremely severe stroke. This was my first experience of stroke in the acute phase. The client was globally aphasic, had a dense hemiplegia, fluctuating consciousness, and was unable to initiate a swallow when food was placed on their tongue. My CE and my partner were going to review their swallowing, as they had been displaying small signs of improvement throughout the week, but were foiled by an ultrasound. I did have an opportunity to talk with a family member, which I think revealed a deficit in my counseling skills.
What I did:
- I talked about the beautiful weather outside
- I said they seemed to be coming from a high-baseline (they were fit and active before the stroke)
- I said the family seemed to be doing helpful things (having pictures of familiar people, talking to them in their home language)
What I should have done:
- Listened more! Allowed the family member more time to talk
- Reflected the family’s members thoughts back
One of my colleagues said it was natural to offer solutions when listening to the problems of others, but sometimes they really don’t need your input. Instead, they just need to be heard.
The second client was also in their 80s, and had entered the health system a few weeks ago upon the discovery of a serious metastasised cancer. I felt overwhelmed on many fronts: medically, the client was complex, with multiple systems involved in confusing (for my poor Speech Pathologist’s brain) ways; and emotionally, as I tried to imagine how quickly this person’s world had changed. We observed an instrumental swallowing examination, where it became apparent that the client was unsafe on all consistencies and thicknesses. One of my Clinical Educators (CEs) showed the client the results and explained them to them. It was difficult to watch, as the client clearly had difficultly coming to terms with the news. I was amazed at the language my CE used, and how she was able to distill the deficit in layman’s terms without being condescending. When the client asked if she thought his swallowing would improve, she didn’t directly answer the question, but pointed towards the next steps – making sure they were comfortable in their feeding.
When it comes to the end of the road like this and palliation is on the horizon, I thought about what one’s goals might be as a Speech Pathologist in this situation. SP involvement in palliative care is relatively new but I found this helpful article from 2004, which distilled the goal to:
To assist in optimizing function related to dysphagia symptoms in order to improve patient comfort and eating satisfaction, and promote positive feeding interactions for family members
I’m unsure if I could top that.
Pollens, R. (2004) Role of the speech-language pathologist in palliative hospice care. Journal of Palliative Medicine, 7(5), 694-702. doi:
I started another placement today at an acute hospital. I’ll still be completing the intensive fluency placement at the same time, which should be interesting as far as time management goes. My fellow student clinicians and I talked with our educators briefly about the competing needs of swallowing and communication in a hospital setting.
Naturally, dysphagia often takes precedence over dysphasia (or aphasia, as we call it at university) – the reasoning is that swallowing difficulties affect a patient’s medical status, whereas communication difficulties do not. Also, hospitals view Speech Pathology services as primarily serving dysphagia, rather than communication, and sets up funding models and staffing models accordingly.
Abby Foster has authored a paper (with collaborators from the Centre for Clinical Research Excellence in Aphasia Rehabilitation) that describes clinician’s feelings on this divide .
She found that:
- Acute SPs report feeling more medically orientated than (humanties) communication oriented, and often defer to subacute SPs when dealing with aphasia [1 p.6]
- Acute SPs report their knowledge of dysphagia greatly exceeds their knowledge of aphasia [1 p.10]
- Institutional policies, barriers and timelines prevent acute SPs from addressing aphasia. Many SPs felt their mix of service provision was out of their control.
- Acute SPs often enter the workforce intending to spend more time than their colleagues on aphasia management, but become ‘instutionalised’ to the practices of their supervisors.
- There is good evidence that communication impairments may lead to “medical errors, negative health outcomes, increased health care costs, reduced compliance with recommendations, and increased falls risk.” [1 p.18]
As part of my placement, I will be redesigning the hospital’s patient education brochures on modified textures. The current brochures are long, and not particularly communication-friendly. I guess this will mean more study into ‘aphasia-friendly’ language and visual presentation.
Foster, A., O’Halloran, R., Rose, M., & Worrall, L. (2014). “Communication is taking a back seat”: speech pathologists’ perceptions of aphasia management in acute hospital settings. Aphasiology, 1-24. doi: 10.1080/02687038.2014.985185
A throwaway remark by my Audiology lecturer caught me by surprise. She said that she sits behind children when training them after they receive a cochlear implant in order that they not rely on visual cues when learning to discriminate speech sounds.
Children and adults with hearing loss cannot simply be fitted with an aid or an implant and then walk away ready to hear. They need specific (and in some cases a lot of) training in perceiving speech sounds (as do hearing people, who do this as babies). However, there is a divide between deaf educators/audiologists about the best way to train listening in this population:
- Auditory-Verbal: No sign language, no visual-cues (i.e. lip-reading) – the child must learn to listen solely through the use of the acoustic signal.
- Auditory-Oral: Children can use lip-reading and contextual cues as well as listening to crack the speech signal.
Of course there are many shades between these two approaches, and countless other approaches to deaf education. Perhaps I’ll just link to the ASHA Evidence Map…
On the other side of the SP range of practice…
I thought it was interesting, because it conflicted with how we do phonological therapy in Speech Pathology, where children who cannot distinguish phonemes are encouraged to perceive both the articulatory and acoustic differences in the sounds. It also is a similar ‘debate’ in Aphasia rehabilitation. One approach is Constraint-Induced Language Therapy (CILT), where clients are restricted to verbal output (no gesture, writing or drawing) through the use of physical screens. A review  found large effect sizes, but since the therapy was intense, it remains unknown whether ‘constraint’ is an important aspect of the treatment.
However, there is another school of thought which claims clients should be able to draw on any residual communication in any form. Such an approach is found in Multi-Modal Aphasia Treatment (MMAT), which a pilot study found to be equally efficacious as CILT. A RCT is in the works.
The danger of single-treatment studies
When your study has only one treatment, even if it has a control, it is impossible to say whether it is a treatment that should be used. If clinicians are to choose the best treatments (which we are not presently required to do, all we are required to do is to use evidence-based treatments), we need more studies like  and less like . Two other examples spring to mind:
- Literacy: Is Reading Recovery more efficacious than a Systematic Phonics program?
- Fluency: Is Demands and Capacities Therapy more efficacious than the Lidcombe Program?
(There is research on the second question  finding equal efficacy, but the Lidcombe program was only administered for 12 weeks, in defiance of best-practice and proscribed standards for its implementation).
When we do therapy, we cannot point to research that proves that every component of the intervention (like constraint) is directly related to a result. Perhaps if we removed it, the treatment would still work. This is where a solid theoretical framework helps. If what I’m doing is reasonable given what I know about the body and the brain, I think I’m a lot more comfortable, even if a small aspect of my intervention hasn’t been checked by an RCT.
- Cherney, L. R., Patterson, J. P., Raymer, A., Frymark, T., & Schooling, T. (2008). Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. Journal of Speech, Language, and Hearing Research, 51, 1282–1299.
- Rose, M. L., Attard, M. C., et al. (2013). Multi-Modality Aphasia Therapy Is as Efficacious as a Constraint-Induced Aphasia Therapy for Chronic Aphasia: A Phase 1 Study. Aphasiology, 27(8), 938-971.
- Franken, M. C., Kielstra-Van der Schalk, C. J., Boelens H. (2005). Experimental treatment of early stuttering: a preliminary study. Journal of Fluency Disorders, 30(3), 189-99.