Megan Berg 0:02
Welcome back, everybody to the Resource Roadmap show. This is where we get to spend the next hour talking about all of the new resources that were just added to the Therapy Insights Access Pass library. I’m your host, my name is Megan Berg. I’m the founder of Therapy Insights and an SLP, based in western Montana. And we have our two writers with us here today, we have Jennifer Leger, who’s based in South Carolina, and she works mostly in acute inpatient rehab, and LTACH. Hi, Jennifer.
Jennifer Leger 0:31
Hey, everybody.
Megan Berg 0:33
And we have Stephanie Henigin with US based in Minnesota. She’s also at a level one trauma center and spends most of her time in outpatient therapy. Hi, Stephanie.
Stephanie Henigin 0:43
Hi, everyone.
Megan Berg 0:45
And I know you just got back from an amazing CEU experience. Can you tell us a little bit about it, just because I know we’re all always looking for those diamonds in this?
Stephanie Henigin 0:54
Yeah. I was really excited to be a part of ASHA’s inaugural healthcare Summit. It was actually hosted in Rochester, Minnesota with the Mayo Clinic Team. So since I’m in St. Paul, I do see the names of the Mayo Clinic speech pathologists a lot. And Dr. Duffy was there too, which was great. But it was just such a great learning day, it was all about motor speech disorders. And I lot learned a lot more about functional speech disorders, which personally I’ve had a handful of patients with. And it’s good to just learn more about that, and know that there are some very great techniques to learn and use. So yeah, the whole course was very, very informative, and it was nice to collaborate.
Megan Berg 1:45
Awesome. Excellent, thank you. Um, so if you are an Access Pass member, you will have instant access to all of the resources that we’re talking about today. And if you’re not a member yet, you can sign up at therapyinsights.com. And we do offer CEUs. For listening to or watching this show, you can just go onto our website and find this show and answer a couple questions. And you just have to have the CEU feature included in your access pass membership to get that credit. And because we’re offering this for CEUs, we do want to verbalize our disclosures which are that all of us are being paid by therapy insights to prepare and present this show. And we are talking about Therapy Insights products. So I’m excited to dive in. We’re talking about lots of different things today from vision related to occipital lobe strokes, coughs, going to be talking about attention some more. And then also talking about feeding and dementia. So I’m going to share my screen so those of you watching can see the resources that we’re talking about. And the first resource we have is called Cough: Is it Strong Enough? It’s a one page resource that has a visual of a person coughing and talks about the mechanisms that can reduce peak expiratory flow rate. So Jennifer, I’ll let you tell us a little bit more about this.
Jennifer Leger 3:05
Yes, so I kind of feel like cough strength is a topic that I hear being talked about more and more kind of amongst the medical speech pathologists, and I’m definitely incorporating more tools in my job to kind of objectively measure our cough strength and also target cough strength. So, coughing is definitely a more complex function than we may think. So it requires intact neuromuscular activity, coordinated use of an open and optimal airway. It requires strong respiratory muscles and an adequate opening and closing of the glottis. And we can kind of think about cough in two different ways. We can think of it as reflexive which is mediated by the brainstem, or we can think of it as volitional or irritant induced, which is mediated by the cerebral cortex. So the medical terminology for weakened or absent cough is called hypotonia. And this can obviously lead to increased risk of aspiration and respiratory infections due to the reduced productive protection of the airway. So with this handout, it kind of talks about cough strike measured by peak expiratory flow rate, and that’s measured in liters per minute, and can be measured by a peak flow meter.
Jennifer Leger 4:24
So for those of you who are watching, I’ll kind of show you this here. This is a peak flow meter that we use at my job. And so I’ll talk a little bit more about this and kind of what these numbers mean here. So this device kind of measures how well a person is able to forcefully push air out of their lungs. And the peak expiratory flow rate can kind of help us determine if a person is going to be able to successfully be excavated or decannulated. Just kind of based on the numbers. So for example, sample if somebody has greater than 60 liters per minute at the level of the endotracheal tube, then that is shown to predict less successful extubation. If somebody has, you know, greater than 160 liters per minute at the level of the mouth, then that is shown to protect successful decannulation. And then just kind of another number to keep in mind. So, if somebody has less than 270 liters per minute, this is associated with increased secretion, retention and greater risk of infection because of that. So those have just been kind of some numbers that have been helpful to me to keep in mind, especially, when I’m working at our long term acute care hospital with our patients who, you know, primarily have trachs and are on ventilators, it’s helped me to kind of understand, you know, when it when they are ready to be the cannulated, to have that conversation with the pulmonologist and with the respiratory therapist to determine you know, if they’re ready, as well as just kind of those individuals who are ready to be discharged and thinking about decannulation.
Jennifer Leger 6:11
So I’ll kind of go over an example of that in just a minute. So I’m just going to bring this up a little bit larger. So I’m just going to quickly go over some mechanisms that cause reduce peak expiratory flow rate. So that can include reduced inspiratory muscle strength. So in general, you want to think of inspiration prior to coughing. Coughing reaches 80 to 90% of the vital capacity of the lungs. The minimum volume required for the generation of an effective cough is estimated to be in the range of 50% of the vital capacity of the lungs. Other things that can kind of cause reduce peak expiratory flow rate include, you know, reduce expiratory muscle strength, reduced ability to open and close that glottis have a you know, have already said airway obstruction, restrictive lung disease, older age and also just kind of reduced activity.
Jennifer Leger 7:06
I wanted to talk about one of the patients that I currently have right now who is a female, she’s in her 70s. She has a history of paraplegia. But that’s not why she’s currently hospitalized. But just thinking about how those abdominal muscles can be affected, you know, for cough strength, because of that history. She has had a trach five times and she was de-cannulated right before this current readmission to the hospital. And during her current hospitalization, she has had acute respiratory failure again, she was intubated she had a tracheostomy. She’s currently stable, she’s tolerating room air, her trach is capped, she’s pretty much ready to be discharged from the hospital. But kind of her only barrier right now is that she is now on hemo dialysis and to receive an outpatient spot for hemo dialysis, you have to be stable, they don’t really like to take trachs. But if you do have one, they have to typically be capped. You can’t have you know, you don’t, you don’t have the opportunity to, you know, be suctioned, if you need that. And so that’s really kind of her barrier right now is because she has a very weak cough. And you know, obviously the pulmonologist does not really want to decannulate her with how many times she has had a trach already. And so she’s still needing to be suctioned, you know, maybe one to two times a day, which isn’t a lot. But we still have to keep that in mind as to how that can affect her, you know, potentially receiving that outpatient dialysis spot. And so we’ve used the peak flow meter to kind of get a baseline objective measure as to, you know, what her peak expiratory flow rate is. And so this meter, or this meter here, it actually starts at 60 liters per minute. And so she was unable to even move the meter on this when we kind of originally started. And so we’ve been working a lot on respiratory muscle strength, diaphragmatic breathing and those kinds of things. And so, this week, she was actually able to get to 100 liters per minute on here. So again, she’s still, you know, 100 meters is, or 100 liters per minute is still indicative of a weak cough, and kind of secretion retention, but it’s just given us, you know, that objective, objective measure which is really helpful when treating these types of patients. So, it’s been something that I’ve really started to use a lot more in my practice.
Megan Berg 9:54
Yeah, that’s great to have the objective data, because I think we’ve all stood there and watched people cough and been like Well, that we know it’s weak or it…
Jennifer Leger 10:03
…sounds weak. But, you know, can we wouldn’t that mean?
Megan Berg 10:08
Yeah. It’s great to remember.
Stephanie Henigin 10:12
I have a question. So does each patient get one or both in the hospital? Or is there between all these hands?
Speaker 1 10:20
No. So we this is one per patient. And no, not we’ve just started ordering these in our speech therapy department. And we don’t give them to every single patient, we just kind of give them to the ones that we know kind of have a weaker cough. And that’s what we’re working on. That’s kind of what we’ve started to do. But it’s still a work in process. I’m still learning a lot about cough strength, and you know, how to measure and target it to so I just, you know, something new that I’ve started to use in our practice, and it has been helpful, I feel like.
Stephanie Henigin 10:57
Yeah, again, I think that’s one of the reasons why maybe I’m not using it is because my facility just doesn’t purchase them. I guess that would probably be the speech therapy department. I just usually go off of what respiratory therapy gives me for information. But that’s good to have more objective data.
Jennifer Leger 11:15
Yeah. And I’m honestly not sure how much these costs. I feel like they’re fairly inexpensive. There’s many different ones out there, if you kind of search a peak flow meter. I might try to look that up while while you’re talking next.
Megan Berg 11:33
Yeah, and I was gonna say this is a great handout to share with any decision makers in your facility, or you’re trying to provide context and justification for why this would be helpful. And then I know, Jennifer, sorry, Stephanie, if you want to guide us through the article snapshot you wrote that ties into this topic, that would be a good resource to share as well.
Stephanie Henigin 11:55
Yeah, so I got found this article, or maybe Jennifer shared it with me. But the use of cough peak flow in the assessment of respiratory function and clinical practice, with the narrative literature review by Brenna and their team. So cough peak flow measures the maximum expiratory flow that occurs during a cough, or when that sudden opening of the glottis. So kind of like Jennifer was talking about kind of the thresholds for when maybe it’s appropriate for someone to be decannulated. This gives us some healthy adult cough peak flow numbers, and they’re saying a normal range is between 360 and 400 liters per minute. And for the gold standard, respiratory therapy would use a pneumotachograph. But however, spirometers and peak flow meters are often the most commonly used, because they’re portable, easy to use, cost effective, and they can reproduce those results pretty well. One thing that the article pointed out was the mini right peak flow meter, which was most common. For people with Parkinson’s disease, the motor component of coughing is typically impaired in those earlier stages. And in the advanced stages, the cough, motor and sensory components are impaired, meaning that people with Parkinson’s may not be able to, in the early stage, really feel the need of when or have that function of a strong cough. And then in the later stage stages, they may not have the motor function for a strong cough, but they also may not have that sensation of when they need to cough. So having more concerns of maybe aspiration occurring, the cough will fail if there’s any sluggishness of closing or opening of one or both of those vocal cords or vocal folds. Because of that unilateral or bilateral weakness, also, having a weaker diaphragm muscle will not allow for that forcible exploration of air that’s needed for a strong cough. Um, so I’ve just found this was really helpful, especially kind of that tidbit for Parkinson’s disease, since I’m a part of our Parkinson’s clinic as well.
Jennifer Leger 14:22
I can practice if you guys want to see if I’m in that healthy normal range. I would love that we, like I said, this is one device per patient, I did just look it up. It’s about $21 that you can get it for. So maybe even if your facility wouldn’t pay for something like this, this might be something that the patient would be willing to pay for if this is something that they’re working on. I typically kind of get the instruction to blow through it like a whistle and to forcefully push the air out kind of as hard as you can so All right, so I got about 420.
Stephanie Henigin 15:04
You are exceptional. We’re not worried about you at all. But thanks for demonstrating .
Megan Berg 15:14
Are there any apps yet? That’d be hard to do. I guess
Jennifer Leger 15:18
This device actually has its own app for tracking.
Megan Berg 15:23
You can track with it. I’m just saying, like, blow into a phone and it’ll give you something but it’s probably not the same. There’s too many, there’s too many variables when there’s an air gap between what you’re blowing into and your mouth.
Jennifer Leger 15:37
I bet it will be there soon though. Someday.
Megan Berg 15:41
Cool. All right. Okay, the next piece is a one page handout called The Five Components of Dysarthria. And it has kind of a, an abstract anatomy drawing of the head, and neck and chest and points out each of the five areas of dysarthria. So Stephanie, Holly, you talk about this resource.
Stephanie Henigin 16:09
Yeah, this has been a dream resource for me. And I’m honestly kind of surprised, it’s taken this long for us to make this one. And this especially, it’s very complementary to the motor speech disorder course that I just took over the weekend. So this handout is meant to just kind of be more of that educational guide for patients and family members, or maybe even some OTs or PTs or some other medical professionals who aren’t quite as aware of dysarthria, and how it breaks down. So I know I do talk about this with my patients. And I usually, like draw this super bad drawing, but now I don’t have to. And just kind of pointing out that dysarthria is made up of five components. As we know, it’s the respiration, the phonation, articulation, resonance, and prosody. And this just does a very simple but complete job, I would say, of just kind of explaining those five components, and really helping you to talk to your patient and their family one on one, and really kind of explaining, okay, maybe the respiration is an area that’s really weak for that person. And that adding in is actually affecting everything else. So because you don’t have a strong respiration, your phonation is going to be weak articulation is going to be hard and whatnot. So I know I will be using this handout as soon as I can with my patients. Because motor speech disorders is kind of a complicated thing for people who aren’t speech therapists who have studied it.
Megan Berg 17:42
So yeah, and I pulled out there is a clinic card with this graphic on it. So for anybody who likes using the clinic cards, they tend to be just a little more basic than the handouts. So if you don’t want the distraction of all the texts on the handout, you can use this and then you can sit down together and label it together. And draw on it. Whatever you want to.
Stephanie Henigin 18:10
Is that something people order from the store?
Megan Berg 18:14
Yeah
Jennifer Leger 18:15
I was going to say the visual is my favorite.
Stephanie Henigin 18:18
Yeah, me, too. I love this visual!
Megan Berg 18:23
Yeah, and it’s great, because there are so many different pieces to dysarthria. And I think when you can break it down into its individual components, and then talk about how you’re addressing each of those components within therapy, or even have individual goals for each component, that can be helpful for documenting progress and helping people see progress, because sometimes it’s slow and hard to notice for the person.
Stephanie Henigin 18:49
And you’re right, it can also even help them understand why this speech task is so complicated, because there’s five components that are involved that most of the time people don’t consider.
Megan Berg 19:01
Right. Thank you. Okay, we touched on attention last month. And we’re going to be talking about it briefly this month with Models of Attention. And so this is a one page handout that breaks down the different components. And I’ll let Jennifer tell us all about.
Jennifer Leger 19:23
Yeah, so this was requested by one of our subscribers, and we do have another resource available that talks about different types of attention. But Solberg and Mateer updated their original model of attention in 2010, with their attention process training program that was created for individuals with acquired brain injuries. And so this handout is kind of based on their updates and describes the following clinical framework for attention. So I’m just going to kind of read through each type of attention or each sub component of attention for those that are listening. So the first is just basic sustained attention. And so this is the ability to maintain attention during continuous and repetitive activities. This includes persistence tasks, consistency and vigilance. So for example, following a brain injury, your person may demonstrate short attention spans, or kind of lose concentration over time. And so this is kind of an example of an impairment and that basic sustained attention. Another sub component of attention is executive control, specifically working memory. And working memory is the processes required for holding on to and manipulating information in one’s head. It allows for a person to hold on to information temporarily and to integrate it with existing information, and then store it into memory. That also allows a person to retrieve information from long term memory and use the following a brain injury a person may have difficulty completing mental calculations or remembering a password. And that can be kind of an example of an impairment and working memory. The next sub component is selective attention. And this is the ability to selectively process target information while inhibiting responses to non target information. The ability to maintain a behavioral set in the presence of distractors or other competing stimuli. And so following a brain injury, a person’s attention may be negatively affected by internal distractions. So we think about kind of emotions, pain, worrisome thoughts, or external distractors as well, you know, noise, too much light, not enough light those different things. The next sub component of attention is suppression. And that’s the ability to control impulsive responding is related to both selective attention and working memory. And so following your brain injury or person may present with disinhibition or impulsivity. And that’s kind of an example of that impairment and suppression. And then the last sub component is alternating attention. And this is the ability to shift one focus of attention. The capacity for mental flexibility allows a person to switch attention between activities or tasks that demand different behavioral responses or sets. And so again, following a brain injury, a person may have difficulty initiating a task after they have been engaged in an alternate activity, or continuing to perform according to the same parameters as the previous task after they were supposed to shift to a new tasks. persons may also show per separation, rigid and flexible thinking so processing, or poor working memory with impairments and alternating attention. And so this handout I feel like is good. You know, for education for the speech pathologist, as well as for the patient and their caregivers. It’s really important for our patients to know what we’re working on. And while we’re working on certain activities, and what it’s truly targeting, for them to be kind of invested in what they’re doing. And so I think it’s always good to, you know, you know, provide that education at the beginning.
Megan Berg 23:13
And we talked last month about sort of what works when targeting attention and what doesn’t work. And the evidence base for that is morphing as we speak. And I think we’re moving more and more towards this therapy approach, where we’re using metacognitive strategies, trying to become more aware of the challenges, and then how can we, you know, put together some compensatory strategies to hold on to more attention, even though we have a brain injury. So I think this is a great handout, because we can talk about like, hey, like you’re not at the level where your basic sustained attention is impaired, we’re really working specifically on alternating your attention between two different things. And so they can see some of the strengths they have, and that it’s not just kind of the blanket term of attention. Because I think when people hear that, or patients hear that, it’s like, we’re working on attention. Maybe it feels a little bit demoralizing, or like, like I’m paying attention to you like I don’t know, what you’re saying is I have that skill, but breaking it down for them even further to help them understand the specific attention skill set that we’re targeting is important.
Jennifer Leger 24:28
I think it’s interesting too how like even under like alternating attention it has the examples of the perseveration and the rigid and flexible thinking so I don’t even normally feel like I always think about those things as like an alternating attention impairment, but just kind of, again, realizing how all this is connected, and it’s hard. You can’t tease things apart.
Stephanie Henigin 24:50
So question… I know in outpatient, I get a lot of questions from patients who their chief complaint is, I can’t multitask anymore. And so I, I guess I bring up this idea of alternating attention because, you know, truly, can any of us multitask? Are we just shifting our attention quickly between tasks? Right?
Jennifer Leger 25:14
Yeah, I feel like that’s a definitely a big topic that you hear and why divided attention is not listed on this handout, because that is kind of a a topic that’s being brought up that can we truly multitask or divide our attention between two different things? Or like you said, Is it truly just shifting your attention back and forth? So that’s a good point.
Stephanie Henigin 25:34
It’s always this kind of internal debate I have, because we can’t really multitask. So what do we identify it as?
Megan Berg 25:46
It’s interesting. So I guess, divided attention would be that I’m working and watching my one year old at the same time, which I don’t think is possible.
Stephanie Henigin 25:58
Yeah, I guess I’m considering
Megan Berg 26:02
taking care of a one year old and working, I can alternate.
Jennifer Leger 26:09
There’s maybe like, some debate for some more simple tasks, like listening to music while you’re cooking, you know, doing something like that might be a little bit easier than Yeah. When you’re thinking about something that the example that you provided. Yeah, you’re really just kind of Yes. Switching that attention. A good discussion to have in the future.
Stephanie Henigin 26:29
Yeah. I’d be curious if any of the listeners have any input on this, too.
Megan Berg 26:35
Yeah, I bet driving would be a big topic of conversation around alternating attention, because that’s another one where you’re, you’re having to shift back and forth. Like if you’re having a conversation and looking at the road, you’re constantly alternating.
Stephanie Henigin 26:55
Yeah, I was doing that driving back from Rochester. I was trying to listen to the three of us kind of talking about what we learned, but also trying to drive it was, it was an attention to ask for sure.
Jennifer Leger 27:07
Which is why they don’t let young drivers have more than a few people in the car with them.
Megan Berg 27:12
There you go. All right. Thank you, Jennifer. Okay, we’re gonna switch to talking about Environmental Considerations for People with Dementia while they’re eating and drinking. And this is a one page handout that basically has a list of bullet points for different strategies to improve the environment for a better swallowing experience for people with dementia. Stephanie, tell us about this resource.
Stephanie Henigin 27:43
Yes, I was thinking about this resource, because I do see a lot of people with dementia in outpatient. And oftentimes I’m talking about these things with their themselves and the patient’s families, but never really had it written down. So the following are just some ideas for improving the environment for a better swallowing experience for people with dementia. So we kind of talked about, I’ll go through these bullet points.
Stephanie Henigin 28:08
So the first bullet point was meal choices. So making sure if the person can communicate a choice, having that caregiver try and give them a choice. So that could be either two options of what they might like to decide about the meal, or just even deciding what they like to drink. The next bullet point is talking about reducing distractions, so really trying to have that quiet place for a meal. Because swallowing at this point can be more complicated and needs more attention, like we have just been talking about. So turning off those televisions or trying to have family members waits to have conversations until after the meal. Positioning is important. I’ve heard a lot of my personal patients talk about they eat sitting in the living room. And sometimes that trunk core strength is kind of difficult, so they might be leaning back while they’re eating. So being maybe at a table, a sturdy chair, 90 degree angle could be the best position for that patient. But also maybe talking with PT and OT and see if they have any insight if that patient is shared, to give more positioning ideas. time making sure that person is fully alert and awake and maybe realizing that mealtimes could be flexible. So it may not be eight, noon five, and really just more gearing that towards the person and when they’re feeling awake. So because with dementia, sometimes that concept of time just doesn’t exist in in in the aspect that we know it. Um, another one I thought was interesting is putting fluid first. So trying to encourage that person to take a drink of liquid first to kind of help moisten up the mouth and the throat to kind of get get ready for eating a meal. Because as we know is there a stoma or dry mouth is common for older adults, whether that’s because of medication side effects or other kind of medical complications I’m talking about, there’s other some ideas for silverware or cups. So kind of looking into those could talk to occupational therapy too needed some specific ideas. And then just kind of the general ones that we talk about with speech therapy. So making sure the person is eating slow, alternating foods and liquids to really help kind of that flushing action. I’m trying to make sure that the person kind of stays upright for about 20 to 30 minutes after meals, they don’t go lay back down in bed right away. And then just really stressing the importance of oral cares and making sure that the person either gets cues or help with brushing their teeth after a meal to kind of reduce any level of bacteria or the risk of pneumonia.
Megan Berg 31:09
Great. Yeah. I think this is a great list of strategies for people to try and see what works for them. And it’s going to be different for everybody.
Stephanie Henigin 31:20
Yeah, I think so often, family members or care partners just want to learn and do the best that they can. And I think this handout is a great starting conversation for the speech therapist and the patient in their care partner to get creative.
Megan Berg 31:38
Absolutely. And Steph, I know you also wrote an article snapshot related to decision management, and kind of shifting towards a more culturally responsive care approach. And some of the some of the recommendations from this article may or may not be able to be applied to the dementia population. I think this is more of an overall dysphagia population approach. Can you tell us more about the snapshot?
Stephanie Henigin 32:12
Sure. So this snapshot is called using backward design and dysphagia management, a paradigm shift towards more culturally responsive care, and I’m gonna butcher this name, but Ambrocio and their team worked on this one. So I really found this article fascinating. And I guess I didn’t realize until afterwards that this is maybe how I personally approach swallowing and outpatient care. So this backward design for dysphagia, management incorporates the patient’s culture and values for their quality of life to guide the treatment. So the speech therapist can use motivational interview questions so such as, how does your swallowing problem impact your life to learn about how the patient is experiencing their swallow ethnographic interviewing questions such as, tell me about your typical squat experience with mealtime before your stroke. And then how is mealtime has been changed now since your stroke and that’s going to allow the speech language pathologist to learn about the patient’s culture and values related to eating and swallowing. So the goal attainment scale can be used to kind of create those shared goals with the patient and their care partner in the speech therapist. And it’s a way that we can measure progress and that personalization for the patient’s goals. And when dysphasia management does consider the patient’s goals and culture, the patient has a better patient centered health care and outcome. So in my practice, I do a lot of the modified barium swallow studies. And I ask a lot of these questions without, before I even read this, this article. And it just really an outpatient, you know, they’re, they’re less acute, they’re probably already, if they’re aspirating, their body may able to kind of take care of it, if they’re not really having a lot of illness. So really just kind of looking at these big questions of how is this impacting you? What changes could we make that it would still kind of fit into your daily lifestyle, it wouldn’t make you feel like socially isolated or it won’t make you change your feelings about eating and swallowing. Um, so it really is patient specific on this one, but sometimes we might talk about if the patient maybe does want to kind of try thickened liquids. Maybe they have them in the evening time maybe when they’re more tired and maybe thinner liquids in the morning. So just kind of these little things that we could just see if it helps that patient and you know it it’s it’s their bodies their quality of life. So I always say, I’m just here to give you education and ideas to make the best choice that you can for your body. And it may change in the future. So then we’ll just revisit this too, or it could get better. So that’s how I personally approached it.
Megan Berg 35:17
Great. Yeah, and I think this is part of the movement of moving away from being the diet police. I think it’s great that SLPs make recommendations. And I think recommendations are an important part of documentation and developing treatment plans. And of course, we want to offer our insight and experience to patients and, you know, give them considerations that we think are valid to think about. But I think the pendulum has swung perhaps a little too far in the control direction, where I see a lot of speech therapists just get frustrated, the patient is not doing what they’re told. Or following the recommendations, they’re not complying. I mean, I always think like, if I or when I’m a patient, and somebody does the bedside swallow or clinical swallow exam, or the video study with me, like I’m gonna be a nightmare for them, because like, I don’t eat meat, I don’t eat dairy products, I would never touch a sandwich with the typical sandwich that you must be presented with the, with the MBSS. If somebody walked in my room and wanted me to eat a yogurt, and like graham crackers, I just wouldn’t do it. So I think you have to like consider that every single person has their own very unique relationship with food. And that unique relationship is vitally important in any conversation we’re having about swallowing in eating. And it’s it has to be the first part of the piece in our treatment approach. So thanks for the article snapshot. And I think it’s a great conversation.
Megan Berg 37:05
All right. The next resource we’re going to talk about is Impairments of Occipital Lobe Strokes. This is a one page handout that talks about different visual impairments that people with occipital lobe strokes might might experience. And what I like about this handout is that there are three visual examples of how that person might be or like how we would perceive that visual impairment. So Jennifer, I’ll let you tell us more about this resource.
Jennifer Leger 37:32
Yeah, so this resources pretty straightforward, like the last one, like Megan said, it just talks about different impairments of occipital lobe stroke. So, just kind of a background about occipital lobe strokes. The occipital lobe processes visual input from the eyes. And a stroke occurring in this part of the brain is actually pretty rare due to the safety mechanism for blood flow called the circle of Willis. So the circle of Willis are arteries in the brain that are connected in a circle and allow for blood to flow backward and forward to compensate for blockages or other damage. And I would agree, I feel like I don’t see strokes in this area of the brain very often, at least where I work. But it’s important to know that this can still happen. There can still be strokes, there can still be traumatic brain injuries in this area of the brain. And so I’m just going to kind of go over different functional impairments that may be observed related to a person’s vision. The first one is Alexia without agraphia. So Alexia is the inability to read or understand written words. Agraphia is the ability to communicate through written expression. So a person with an occipital lobe lesion may not be able to read or understand written words, but can still communicate by writing. How crazy does that kind of sound. So this is due to an impairment in the costs in processing visual input, not an actual language impairment. Another functional impairment related to occipital lobe strokes is something called central vision loss. And what this is, is a person with an occipital lobe lesion may have loss of vision in the center of their visual field. And this is kind of one of the examples that we have on this handout. Another functional impairment is cortical blindness. A person with an occipital lobe lesion may lose all vision due to the visual processing abilities of the brain being damaged severely. So I’ll talk a little bit more about cortical blindness in a minute with a few patients I’ve had recently. The next functional impairment that you may see with an occipital lobe stroke is hemangiomas, hemionopsia. And so a person with this may lose vision on the opposite side of the visual field from their lesion. This is important to know because you might also hear it as a visual field cut, but it is different from neglect, where that is actually an attention impairment. So you might hear like left neglect or left visual field cut and just knowing that those two things are different from one another. Alright, let me try to say this next one’s the next functional impairment. So prosopagnosia. Um, and this is a temporal occipital lobe lesion, where a person may not be able to recognize familiar faces. And oftentimes, a person can still recognize familiar people by their voices, though. This is also kind of known as facial blindness. Another functional impairment is visual agnosia. And a person with this may not be able to identify familiar objects by sight, maybe they are still able to kind of identify objects by touch, kind of using some other senses to help with that. And then the last functional impairment is visual hallucinations. So less common than other impairments. A person with this may have vivid hallucinations such as colorful pinwheels, lights, sparks, and other things. And this is also kind of one of the examples that is shown on this handout. So I wanted to talk, you know, kind of my inspiration for making this handout came from two patients that I’ve had recently at the long term acute care hospital. And so they’ve been very challenging to treat, they both have cortical blindness, because we’re not able to use kind of the traditional tools, such as external aids for memory management. One of these patients also has receptive aphasia or language impairment. And so, you know, they’re not able to see gestures or key written words, again, things that we typically might use to treat these other impairments. And so, you know, these patients have been, you know, a very big challenge for me in trying to figure out what does help them. It just kind of background on both of these patients, they both kind of survived multifocal or occipital strokes. Interestingly enough, so one of them was following cardiac arrest. And another one was spark following an aortic injury due to a car accident. And so just kind of interesting to see they both kind of started with the heart, and then ended up having a stroke. And both ended up with that cortical blindness. But I just wanted to, you know, have better information about the different types of impairments that you might see to kind of tease some different things apart. You know, I definitely have seen the cortical blindness in my practice, I’ve seen the visual field cut is visual hallucinations. I’ve had patients that have had those indefinitely, Alexia and agraphia. What about you two? Have you had any patients with any of these functional impairments?
Stephanie Henigin 42:52
I have, I was actually just looking it up because I remembered, Brad Pitt came out. And he disclosed that he has propagnosia, that facial blindness. I just googled it to double check that I didn’t just make that up. But I thought that was interesting to kind of see a celebrity kind of come out and disclose that.
Megan Berg 43:18
Yeah, and I worked with someone with alexia. And it wasn’t like, there were some treatments that had been started as far as like, creating a memory book and writing things down and then like it slowly became because he was so good at overcompensate overcompensating and like kind of you couldn’t really tell that he had alexia. But then we figured out that he couldn’t actually read his memory. And so then we completely shifted and started working on phonemic awareness. But I think what’s interesting too, is like, especially when people have any kind of aphasia, and you’re trying to use tool like visual tools to help with communication. This is a really helpful handout to try to figure out like, what might be going on with their vision, because you can’t always ask questions to figure out what they’re seeing or not seeing that. You might not be able to share that.
Jennifer Leger 44:15
Yeah, as I say, with these patients, I’ve definitely talked with my occupational therapist a lot just because they are typically the ones that kind of assess vision a little bit more. And so they’ve been able to kind of brainstorm with me on different things that we can try.
Megan Berg 44:33
Yeah, absolutely.
Megan Berg 44:37
Yes. All right. Okay, so we’re gonna move on to our case study. This is the last part of our show. And this is a chance for us to talk about different clinical approaches and perspectives, with different case studies. So this month we’re talking about Joe. Joe is a 72 year old male with COPD, chronic obstructive pulmonary disease. He’s who is frequently readmitted to the hospital, due to what the doctor refers to as, quote, non compliance with medications. You note that while Joe doesn’t have a neurological diagnosis, the OT shares with the team that he scored a 19 out of 30 on the MOCA, and it’s unclear if he is non compliant or simply unable to manage his medications successfully at home. Joe isn’t current currently on your caseload? So the question is, what would you do? What resources would you put in place to address Joe’s situation? Stephanie, what do you think, in the sort of stuff?
Stephanie Henigin 45:38
So first, I would reach out to my neurology team, and I’m spoiled in the fact that they’re on the third floor, and I’m on the first floor, and I know them very well. And so I would maybe bring this up to them and say, hey, just so you’re aware, this patient is seeing ot right, but not speech, is that the case, okay, and just kind of saying the OT is kind of telling me that they’re scoring and it had a 30 on this Mocha, this could be something that maybe we need to dig a little deeper in as a team. I know not a lot of people can go up in that sense of like going out and seeking out the neurologist and saying that this really needs to be addressed. But again, I’m not afraid to do that. But then probably getting an order to get this person on my caseload. And one thing I would kind of look at is more memory aids and memory strategies for medication. So I don’t, I don’t really know, Joe, if he lives alone, or if he has family or friends that help him, but maybe, with his permission, kind of including them in that evaluation, and talking about some strategies. So if maybe he lives alone, maybe like that pillpack.com, where he could get his medications, and those little baggies, if he’s not really tech savvy, probably not like an app or something like that. Maybe medication boxes if he’s really kind of wanting to start more simple, and then help him kind of set up recurring reminders. Um, there’s a lot of things, a lot of questions. I have those still, but I think that would be a good starting point.
Megan Berg 47:25
Yeah. Yeah, there’s a lot of unknowns. In this case, I think. It depends on your facility. Like you’re saying, you’re really you have good access to your neurology team. And not everybody has that. Not every facility sits in has interdisciplinary meetings. So it might not even come about that you may like just happen to hear that the OT did a mocha and they scored low. And you’re kind of picking up on these different details about this person, but they’re not on your caseload. I mean, that may or may not happen, depending on where you work. But yeah, I think that’s a good place to start.
Megan Berg 48:03
What about you, Jennifer?
Jennifer Leger 48:05
I was having a really hard time picking a good resource for this one, I felt like I could go in kind of different directions. So I feel like this is a little bit random. But so this is a handout about acquired brain injury. So specifically related to this case, I’m looking at kind of that loss of oxygen, oxygen on here to this anoxic brain injury but more thinking of hypoxic brain injury with somebody who has COPD. So I know that it was mentioned that this person doesn’t have a history or at least a documented history of any neurological damage. And so just kind of thinking about, well, if they don’t, what are some other reasons that this person may be having some difficulty with memory or organization, or just kind of those activities of daily living? So, you know, this, this handout goes over just kind of what an anoxic or hypoxic brain injury is kind of that reduced oxygen in the blood flow. So COPD can cause kind of reduced oxygen saturations. Oxygen saturation levels, or hypoxia, as we call it. And hypoxic tissue injuries are an injury resulting to your tissues due to not getting enough oxygen rich blood can happen when somebody’s oxygen saturations are less than 90%. And so we want to, you know, make this aware to the person that has COPD if they’re not aware of how kind of those low oxygen levels or COPD exacerbations can affect cognition and affect kind of the tissues in the body. And so I think it’s really important for them to understand that too, and just how that diagnosis of COPD can lead to neurological changes as well. If it isn’t in know if their oxygen isn’t monitored well, and they’re not kind of watching out for those times where it does kind of dip lower, they may need some supplemental oxygen. So I think it’s really important just to kind of give them that background education as well. And I’m gonna say I use this handout, as well as another one that we have to kind of talk about this. So this is actually an OT handout that was created. And it’s called the dangers of hypoxemia, or low oxygen, and it has some really good information on there, too. So if you’re interested, definitely check that one out, as well.
Stephanie Henigin 50:31
And I also kinda like to piggyback on that and explain to patients that the hippocampus, the memory center is very sensitive to any changes in oxygen level. And so that is the first one to get damaged. And it doesn’t take much, much time. I think it’s only like minutes without oxygen, and it causes damage. So that’s kind of where I go with that, too.
Megan Berg 50:59
And then, the last month, we talked about the Apple Watch. And I was looking at the Apple watches in the new version has basically a an oximeter on it. Am I wrong
Stephanie Henigin 51:13
is Yeah, no, it does. It’s kind of main mainly for like, you know, people who go camping in high altitudes where they might have less oxygen, but it still will tell you if your oxygen level has dropped.
Megan Berg 51:27
That’s cool. Maybe talking to him about monitoring his own levels if he’s able to. Yeah. Did you have either of you have any other thoughts before I share mine?
Stephanie Henigin 51:43
You went for an oldie but a goodie!
Megan Berg 51:45
A oldie but a goodie! It is old 1992. This is an article called Patient Non-Compliance: Deviance or Reasoned Decision Making? And it is an older article, although I feel like a lot of these types of articles have been kind of sprinkled into the publications since the 1970s. And it’s this ongoing conversation of trying to shift things away from this traditional medical model. And so I just I want to read the abstract really briefly just to get give you a sense of what this article is about. And this article is available for free online. So if you work in a facility or on a team where you share articles with each other, this would be a good one to share.
Megan Berg 52:19
So the abstract is a large quantity of research concerning issues of patient compliance with medications has been produced in recent years. The assumption in much of this work is that patients have little option but to comply with the advice and instructions they receive. Studies have shown, however, that between 1/3 and one half of all patients are non compliant. But different authors cite different reasons for this high level of non compliance. In this paper, the concept of compliance is questioned, it is shown to be largely irrelevant, it is shown to be largely irrelevant to patients who carry out a cost benefit analysis of each treatment, weighing up the costs and risks of each treatment against the benefits as they perceive them. Their perceptions and the personal and social circumstances within which they live are shown to be crucial to their decision making. Thus, an apparently irrational act of non compliance from the doctor’s point of view may be a very rational action when seen from the patient’s point of view. The solution to the waste of resources inherent in non compliance lies not in attempting to increase patient compliance per se, but in the development of more open cooperative doctor patient relationships.
Megan Berg 53:51
So as we’ve been saying, like this is a case where there’s a lot of unanswered questions, a lot of unknowns. Is this a cognitive impairment? Is this a personal choice? Is it a situation where he cannot afford the medications, he cannot get to a pharmacy to get the medications. He doesn’t think the medications do anything. He’s somebody whose body is sensitive medications. He’s maybe his whole life, he’s tried to avoid taking medications. Maybe he feels healthier when he doesn’t take them. Maybe there’s side effects that people aren’t hearing or taking seriously. So I think there’s so many things to look at here. Like maybe the OT could address any cognitive impairments or medication management issues or access issues. Maybe if you have a relationship with a doctor, this is a conversation that you could start with them and start with your team. Because I think, you know hospital readmissions are enormously costly. And I think it’s frustrating for everybody involved because I think there’s a lot of like throwing hands up in the air and be like, you know, what did they expect us to do, and they’re just not doing what we tell them to do. And I think it just comes down to relationships and really seeing the individual person, and getting rid of that phrase noncompliant and moving in a direction where we are holistically trying to address the situation. So that’s one resource that I would use. And then this is a free resource, you can find this on the therapy insights website under free downloads. And it’s a brief comparison of medical models. And I think when we’re comparing the traditional medical model to the social model, one of the biggest differences is the central focus. So in the traditional medical model, the focus is the diagnosis. In this case, the COPD, or is in the social medical model, the, the central focus is the person. And I think ultimately, that has to be the conversation that’s had across the interdisciplinary team with this case study. Because we need to be focusing more on the person and less on the diagnosis. But I think that’s a hard thing for everybody to wrap their minds around when medication is such a simple and effective solution to the problem. But obviously, the problem is compounded because the person is not taking the medication. So there’s more deeper underlying issues that we have to solve, than just making sure they get the medication in their body. So yeah, any other thoughts about the case study?
Stephanie Henigin 56:40
I guess I was just kind of sitting here thinking about, you know, me, Stephanie, when I was like a brand new grad student, right, like I graduated, and I might my own speech pathologist. And you know, you think about all we learned about is the diagnosis and treatment, diagnosis and treatment, and maybe schools have changed since then. But I just didn’t have the competence as a new grad, to really kind of, I guess, just be okay with looking at the person. And, you know, you focus so much on the diagnosis. So I think, you know, I’ve almost been a speech pathologist for nine years now. And it’s, it’s amazing to see kind of how my experience and how my training and my, my shift, it really has gotten to the person now. But I also just, I know, it’s overwhelming for new grad students. And so I guess I’m trying to say like, it’s, it’s okay, you’re doing the best you can with the limited experience you have as a speech pathologist, and you’ll get there. So even if you just kind of take moments to try and identify the person, but I know that you know, in school and in your practicums, you’re ingrained to like, what’s the diagnosis? Like, thinking about that? So I was just kind of doing some reflecting over here, as you were reading that article, but I don’t know. Do you guys have any thoughts on that?
Megan Berg 58:00
Yeah, yeah, go ahead, Jennifer.
Jennifer Leger 58:07
I’ll just say, I agree, I definitely think it just takes time and experience to get there to kind of get that clinical judgment to go along with kind of that diagnosis and treatment component, and also kind of bringing in that person centered care.
Megan Berg 58:22
Yeah, and I think for any new grads listening or newer clinicians, there’s, there’s a lot of push to to use, like standardized assessments. So in this case, it would be totally legitimate to look at Joe and be like, we need to do a standardized cognitive assessment to figure out if this is a cognitive issue or not. And that’s a totally reasonable path to take. I think another totally reasonable path to take is to have a conversation. And I think that’s something that I wanted to be a voice in this community to keep pushing for, because standardized assessments are a great tool. They are also historically very ableist and racist and classist. And so I think that’s something that we have to keep in mind as well. And so depending on the situation, we might get more out of a conversation. And I don’t think that that’s any less skilled than giving a standardized assessment, if that makes any sense. But I do think it does take time to develop the skill set and the perspective and then also to have these hard conversations with doctors and your therapy colleagues. Because everybody’s going to have a different experience a different perspective, different goals that they’re working with, for this patient in within the facility and within the healthcare system. And so, Stephanie, I’m glad you said that because this is a lot cuz it’s a lot to consider as a new grad. And I think it does just come with experience.
Stephanie Henigin 1:00:05
Yeah, it does. Because then you got to think about it. It’s each patient, you see, you get a little bit more experience with seeing that. Whatever diagnosis it is, but then you’re like, then you think about the person and how they reacted and what their values were. And then it kind of trains you into thinking in a global, like a larger global mindset about your patient. And so, yeah.
Megan Berg 1:00:30
Great. Okay, we’re gonna wrap up this episode of the resource roadmap show, so you can get instant access to everything we’ve talked about today at therapyinsights.com. All links are available in the show notes. And if you have any questions for us, it can be about any resource recommendations we have any particular case studies you’d like us to discuss, you can reach us at support at therapyinsights.com. If you’re an Access Pass member, be sure to vote for what we create next. We do listen to all of your requests, and we do produce the content that you let us know that you need and we’ll have a new episode, new episode for you on June 1, and we will see you then. Thanks, everybody. Bye everyone. Bye