Megan Berg 0:02
Alright, welcome, everybody to the very first episode of the adult SLP edition of the resource roadmap show. This is something brand new we’re doing here at Therapy Insights. And to borrow a word from Glennon Doyle, we are feeling a little bit “skited” about it — a little scared and a little excited, because it’s something we’ve never done before. We’ve never seen it done. And we’re just making it up as we go along. And we hope that this is useful for all of you listening and watching. And if there’s anything that we can do to make it more useful for you, we would love any feedback at anytime you can reach us at support@therapyinsights.com. And if you’re subscribed to the Access Pass, you’ll have instant access to print any of the resources that we’re talking about here today. And if you’re not a member, you can go to therapyinsights.com and sign up. And you’ll get instant access to all the resources we’re talking about, as well as hundreds more inside of the library. And we do offer CEU credit for watching or listening to this show. And so to do that, you just have to have the CEU feature included in the Access Pass. And you can go to our website and go to Access Pass and then click on CEUs and find this show. It’s adult SLP show number one, and you can just answer a couple of questions and you’ll get a certificate of completion for ASHA CEUs. I’m your host, my name is Megan Berg. I’m a medical SLP located in western Montana, I spend a lot of my time running Therapy Insights. And then I also work PRN at a hospital. And right now that’s a couple of days a week. And I want to introduce you to our amazing talented writers that are here with us today. And they’re going to be here with us at every show to talk about these resources. So first we’ll start with Stephanie Henigan. Stephanie is located in Minnesota. And you can see behind her beautiful bookshelves. She also runs a Bookstagram which I would not know what it was if I didn’t know Steph and Bookstagram is an Instagram account all about books. So if you love reading, you definitely want to check her out @stephsbooktherapy on Instagram. But Steph, tell us about your SLP world when you’re not reading books and talking about them on a screen.
Stephanie Henigin 2:28
Yes, so SLP world is my passion first. The books come second. But I work at a level one trauma hospital in St. Paul, Minnesota. I do primarily work outpatient therapy with adults. So it’s usually 16 and older. But I do on occasion help out in the hospital as well when it gets busy. So I do acute care and inpatient rehab. Primarily our caseloads are people with strokes or brain injuries. people with Parkinson’s, dementia, primary progressive aphasia, we do AAC evaluations. We do have some voice therapists who do voice therapy. So I typically don’t do that beyond the Parkinson’s. I also am a part of the Parkinson multidisciplinary clinic in our outpatient setting. And I’m a part of the ALS our our clinic as well. So we have that three times a month. So it is busy. But love I love it. It keeps me excited about the discipline and helps prevent burnout. Because, you know, that’s a real thing.
Megan Berg 3:41
You get to do lots of different things. Awesome. Thank you. And then we also have Jennifer Leger who’s located in South Carolina. And so Stephanie and I are just commiserating that her weather is forecasted to be in the 80s, where ours is forecasted to be in the single digits next week. But Jennifer has two adorable little dogs. And she also has a really great how I became an SLP story, which I feel like I don’t have, I was working in Boulder, Colorado, and I was kind of bored at work one day, and I just looked up grad school programs that were available near me. And that’s how I found speech pathology. And at the time, I was working with geologists, and I was an education outreach specialist. And so all of the work I was doing is interesting. Like I got to travel all around the world and work on all these different research projects all over the place with lots of different people from different countries. But at the end of the day, it was all about rocks. And rocks are fascinating. They’re more interesting than I would have ever known not working for geoscientists. But I also wanted to work more with humans. And so that’s what brought me to speech pathology. But Jennifer, tell us your story of how you became an SLP and what you do as an SLP.
Jennifer Leger 4:59
So my dad actually had a stroke when I was in high school. I was a junior at the time. And as a result of that stroke, he acquired aphasia. And so, you know, my knowledge of speech pathology was very limited at the time. And I learned a lot just from him having his stroke and watching him work with SLPs in the hospital, in an outpatient setting. So he’s definitely my inspiration and why I became a speech pathologist, and why I really, you know, enjoy working with that population. I work at also level one trauma hospital in Greenville, South Carolina, I am mainly in the acute inpatient rehabilitation setting, I also have transitioned over to our long term acute care hospital this year as well. And so I’m getting a lot more experience with working with the trach and vent population, and just expanding my knowledge with that, something that was very limited before this year. And so that’s been really exciting. I also run our lead our aphasia support group in the area, which you know, as a result of COVID, we had to stop for a little while, but I’m in the process of getting that started back up. And we’re hoping to start back in April. So really excited about that.
Megan Berg 6:27
Excellent. Thank you. At this time, since we’re offering this show for CEUs, we want to verbalize our disclosures. So all of us are being paid by Therapy Insights to run this show. And we are also talking about Therapy Insights products. And so the way that these shows will work is this is something that’s been requested for years is for us to provide more context and instruction for how to use the resources that we provide. And so every month, as you guys know, we release new content into the library, and members get to vote on what we create next. And so with each episode, we’ll be talking about all of the newly released resources that we’re putting out that month. And then we’ll wrap up the show with a case study. And that gives us a chance to talk about different clinical perspectives and ideas of how to approach different cases, as well as resources from the existing library that we would use for that case. So we have a great lineup of resources, we’re going to be talking about crushing meds, determining decision making capacity, spaced retrieval, lots of good things. So we’re gonna go ahead and dive in. And I’m going to share my screen so we can see the resources as we talk about them. And we’ll start with this first piece, which is medication swallow strategies for people with dysphagia. And Stephanie, you wrote this piece. So go ahead and share about this resource.
Stephanie Henigin 8:04
Sounds good. So this one is one that I personally wanted for a long time, because it’s a topic that I talked about with my patients, probably daily. But we the votes came in, and one so we made it. So I usually use this, well, I will be using this handout, it doesn’t exist yet. For my patients with Parkinson’s swallowing medications is usually one of the first things I talk about as a sign that they’re noticing about swallowing changes. So this could be a good handout for that. It also could be a good handout for people with brain injuries or strokes as well, because you know, swallowing is a big concern that we work on as well. So this one was kind of compiled with a some discussion from other speech therapists, my experience, and research. So just some basic kind of things that we talk about with our patients. But now it’s all in a handout. Because I know a thing we talk about a lot is health literacy. And, you know, when the patients are with us in a session, they’re taking in a lot of information, but they’re maybe not capturing all that information long term. So if we can just give them a handout to kind of help re kind of explain what we talked about, that visual memory of the handout can really help as well. So of course, you know, we talked about taking one pill at a time. One that I found this kind of interesting is really pushing, take your medications with water instead of juice or coffee or anything else, because that could potentially change the medication effects. So that was something I thought was interesting. I usually don’t talk about lots of water with each medication. Maybe starting with the smaller pills first and working your way up to the The larger ones, because there has been some research that show even healthy adults have trouble swallowing pills. And you know, you have that, oh my gosh, this is maybe the time it’s going to be hard to swallow again. So it’s, it’s normal for healthy people, too.
Stephanie Henigin 10:17
And I think that’s also important to just kind of think about some products that I thought were interesting. I hadn’t really looked into this, but a pill swallowing cup. So there’s a couple different ones on the market, where you have a cup, and there’s like a little spout, you put the medications in the spout, and then you just kind of take both at the same time. So there’s not really that delay of putting the pills in, and then drinking the water, it’s, it’s helpful for some people. Another idea is some pill swallowing gels, so just kind of puts a little bit of an extra coat on the pill to help swallow crushing medications. You know, it’s something we do talk about. But I really stress that this needs to be talked about with the doctor first, because crushing medications can change the effectiveness of that medication, putting a crush medication in applesauce, I don’t know, that could also maybe change things. So have that discussion with the doctors first. If a pill isn’t able to be crushed, maybe talking about an alternative, maybe a liquid. This is also kind of that is a big topic I talk about in our ALS clinic as well with patients, especially with that bulbar onset of ALS. That’s usually the swallowing and the speech is the first to go. So we do talk about how are we going to swallow the pill safely? Do you want a feeding tube or not? If you don’t, then we get creative. But if they do, then we can usually get those medications through the feeding tube. So I’m personally super excited for this handout. I wish we had it a long time ago. But you know what it’s out now. And it’s perfect.
Megan Berg 12:05
Yeah, and I like this because even if you’re you have a moment or a session, let’s say to talk about medications, while strategies with a patient. Maybe the family isn’t present for that, or maybe they’re experiencing a neurodegenerative disease or things that are going to change over time. And so being able to leave this information with them that they can read, and maybe, maybe they’re going to go home. And after reading this, a few months down the line when things are worse. And they think to themselves, I’ll just go get a pill Crusher and crush everything. Maybe that will trigger them to call their doctor in, avoid some of the issues that can come with it. So yeah,
Stephanie Henigin 12:50
Another thing too is people try to take those capsules and open them up. And just like pour that in, but that really changes the effects of the medication. So there’s a reason for that capsule to get to a certain part of the body before that medication is absorbed. So yeah, I think this will be a helpful one for sure.
Megan Berg 13:09
And I kind of want to try that Oraflo pill swallowing. Like you get the water in the pills at the same time. So then you don’t have like a psychological issue of oh my gosh, like I have the pills in my mouth. And now somehow how I have to get water in there without that thing.
Stephanie Henigin 13:26
I personally use the chin tech strategy, I find it really helpful. But I don’t know, there’s, there’s some opinions on that people are just like, No, I have to throw my head back. That’s the only way. So then we got to talk about protecting that airway and why that’s maybe not the safest way to do that.
Megan Berg 13:45
Right. Or if that’s what they do, and you have access to instrumentals, like give that a shot? Well, you can see what
Stephanie Henigin 13:52
Yeah, I do swallow studies on Tuesday afternoon, so we could do it.
Megan Berg 13:58
Cool. All right. Thank you. We’ll move on to the second new piece that we’ve added to the library. This was written by Jennifer and it is the SLPs role in determining patient decision making capacity. This is such a huge topic. And this is such a great resource. And Jennifer, I’ll let you tell us about it. No.
Jennifer Leger 14:19
Yes, so definitely kind of going in a different direction with this resource. So this one was really kind of made more for. I feel like the SLP as the audience and just given you know, fellow speech language pathologists information on kind of what our role is with patient decision making capacity. Kind of the idea came to me to make this resource working in you know, those settings that talked about the acute inpatient rehab, long term acute care hospital, you know, the main screen of our medical record system, specifically states patient capacity, you know, are they incapacitated and also gives further information about, you know, their ability to consent And, and so, you know, just kind of got me thinking further about, again, what is an SLPs role in patient decision making capacity, because it seems like that would be something that we would be a part of. And what I learned from kind of my research is that really anybody who has knowledge of the case and rapport with the patient can kind of be a driver of this discussion. And, you know, like I was saying, I felt like our knowledge and work as SLPs brings vital information about, you know, information that they use to determine if a person has a decision making capacity.
Jennifer Leger 15:41
Depending on kind of the level of care that you’re working in, we often use, you know, in depth evaluations and treatments of those cognitive and communication impairments. That, like I said, directly relate to those factors that are considered when determining if a person has decision making capacity. So kind of looking at this material here, it talks about those four components, and those components are, you know, communicating a choice, does the person have a way to communicate a choice, you know, it doesn’t have to be verbally, it could be by writing their choice, or it could be by, you know, winning, there are many different ways that our patients express themselves, and just making sure that, you know, that we communicate that with other staff members, that that is their way that they best express themselves and can communicate information. Another component is understanding, you know, does the person understand the information that is being said to them, Do they understand it well enough to make a decision, appreciation, you know, does a person except that, you know, this is their diagnosis, and that, you know, it is, you know, maybe degenerative, and that it is going to get worse over time. And also rationalization and reasoning, you know, can the person kind of weigh the pros and cons of a certain treatment, and things like that, in order to make decisions, I feel like, again, we assess these areas in depth a lot of times in our evaluations, and I feel like we can bring a lot of information to that conversation. So that, you know, when the doctor does put that in the system, they have, you know, that information and that knowledge to make a good decision. And so just, you know, as SLPs, I feel like, you know, we can explain how impaired language is not synonymous with impaired intellectual abilities. And also just, you know, make sure that the person has access to adequate AAC to assist with communication.
Jennifer Leger 17:50
So, like I mentioned, like a low tech board or a high tech device. So for example, right now, I have a patient who, you know, very low language abilities after having a stroke. And he’s very unreliable right now by nodding and shaking his head just to answer, you know, basic, yes, no questions. However, when you put a basic communication board in front of him with the written words, yes, and no, his, you know, reliability significantly improves. And so I think that’s really important, you know, again, to communicate that with everybody that’s involved with working with this patient so that, you know, that they can make decisions. Even if it’s on the basic level, you know, they have that ability to do that. There’s one kind of comment in this material that I think really sticks out is bolded. At the bottom, it says decisional capacity should not be based on a diagnostic label, but a person’s functional abilities. You know, just because somebody has had a stroke, they shouldn’t be labeled as not been able to, you know, make decisions, you really need to be based on their actual abilities. And, you know, whether they have, you know, the ability to communicate the choice, the ability to understand and to reason, like I had mentioned before, it’s funny that Stephanie kind of mentioned health literacy in the last resource, but this is something that I thought about when I was making this resource as well. There was actually a resource in the past that I made specifically on health literacy, that talks about, you know, individuals recall and understand approximately 50% of what health care providers explained to them. So, again, you know, just us having that knowledge and understanding just making sure that you know, other providers know how to best educate you know, these patients and how best they understand the information to be able to make decisions. Thank you.
Megan Berg 20:00
Yeah, and I think it depends on the setting as far as like, because ultimately the physician is the one to, to determine decision making capacity, right, like in an inpatient rehab setting, you might have a physician who’s able to be very present with the patient get to know them every day. Whereas in a skilled nursing, setting, assisted living, they may not see the doctor that much. And so these physicians have their own caseload that they’re trying to manage, and they barely have the time to be doing the kind of work that we have the capacity to do. And it’s, it’s a little scary that like, we’re all very, like, it’s a thin line for any of us to lose our decision making capacity, rights just as far as patients. And as soon as that gets entered into the medical record, it’s hard to undo that. So I think the more that we offer to patients to make sure that that’s being done correctly, the better.
Jennifer Leger 21:00
I think, like one of the myths says, you know, decision making capacity is not all or nothing, you know, it might be that I’ve seen in my patients charts, where, you know, they have the ability to consent to basic information or, you know, questions, however, more complex medical care, they have the inability to consent to that.
Megan Berg 21:28
Okay, and then Steph, you wrote an article snapshot about this topic? Yes, I did. Yeah. Can you tell us some of the, or tell us what the paper was? So if people want to look it up?
Stephanie Henigin 21:42
Yeah. So the paper, the paper was called, Help Me Tell You What I Want: Decisional Capacity, Neurogenic Speech and Language Impairments, and the Law in 2018 it was written by Kapp and his colleagues. This one that Jennifer actually shared with me as she was working on this, the materials we just talked about. And just kind of highlighting that decisional capacity is the working and practical, actual legal clinical judgment about a person’s abilities to make autonomous choices about a specific matter during a particular timeframe. So I think, again, it just stresses the importance of, yes, maybe a person in acute care isn’t able to make a decision based on what they’re going through. But I think this is something that should be continuously evaluated by the team. It’s not a one and done. So luckily, that’s kind of how we practice in the hospital I work in because you know, the diagnosis change. Well, the diagnosis doesn’t change, but their acute illness changes in their body’s healing process to it can change. So we continuously evaluate this and the speech therapist was a really important member of that team where I work. Another highlight was a person’s impaired language abilities is not synonymous with their intellectual impairment with Jennifer kind of mentioned. And then again, it talks about how the speech therapists is that crucial team member in determining how the patient best understand language, and can help with those education to the other team members and the family on how to kind of incorporate communication supports to support that understanding of language and allow that patient to communicate what they’re wanting. The SLP can also advocate for assessment modifications to make things more aphasia friendly. Little changes, like Jennifer talked about having a yes or no board or having just a couple pictures with some words, can really just make the difference. Even just like writing the what you’re trying to say in simple language, as you’re saying it, those two together could support that person’s understanding to better make a decision. And then for a person who had a stroke, this decisional capacity will likely be be returned as that person continues to improve to therapy. So again, just reiterating, this is not a one and done. This is a evolving decision about their decisional capacity. Thank you.
Megan Berg 24:33
And the next piece we’re going to talk about is saliva anatomy and function. And Stephanie, you wrote this piece, so go ahead and tell us about it.
Stephanie Henigin 24:42
Yeah, so I talk about saliva a lot with my patients who have Parkinson’s or I also have patients with sjogrens syndrome. And I thought it was just I was Googling like images and trying to share them with my patients and it was just hard and I was like, this would be a great idea and In the subscribers wanted to so I’ve made it happen. But what I like about this is the graphic is beautiful, I love the graphic, and it has a great job of like where the location of these glands are. And then it then goes and breaks down, because saliva, people don’t realize you have like a watery saliva, but then you also have a thicker saliva. And the combination of those two can help with you know, breaking down food. It’s also related to your body’s like response. So that fight or flight and freeze, that creates a different type of saliva. I believe that one is the mucus saliva. So the thicker one is when that fight or flight happens, so, you know, when you’re getting anxious about something like wow, my mouth is like really thick, or I feel like I don’t have saliva. Well, that’s because that thicker mucus is coming in, versus the serious or the watery saliva is that brain that kind of regulating just when we’re at rest our digestive functions and all that. So I’m not going to go through each of the glands because you can read it, but it’s the sublingual glands, the submandibular glands and the product glands. And then it really does a good job of breaking down which type of saliva is produced, maybe how much the parotid glands which are located in the back by the ear, which is about the size of an egg roughly. That one produces about 25% of the total saliva someone has just sitting at rest, and the other to kind of kick in for other other functions.
Megan Berg 26:48
Yeah, I did not realize that different glands produce different types of saliva. So that makes total sense where you can have one gland that’s under producing or over producing. And that will manifest in different symptoms for different diagnoses.
Stephanie Henigin 27:04
And I didn’t even write it on the handout. But a lot of I see a lot of people with had neck cancer too. And they were getting radiation. And so of course these glands are affected, and saliva or lack of saliva xerostomia, the dry mouth is a very common thing they’re talking about with me, and how do we manage that?
Megan Berg 27:26
Great, thank you. And then you also wrote an article snapshot on this topic as well.
Stephanie Henigin 27:32
I did. So since I’m on the Parkinson multidisciplinary clinic, we do talk about saliva and drooling a lot. And I just thought it would be interesting to learn more about it. So the article is drooling rating scales in Parkinson’s disease, a systematic review. It was done in 2021 by Nascimento. I’m gonna say I don’t think I pronounced that right. And their team. So some of the highlights is they were talking about how drooling is often one of the most bothersome non motor symptoms for people with Parkinson’s, and how it has a neck negative physical and psychosocial impacts. My patients talk all the time about how they’re embarrassed, they don’t really want to socialize, they don’t want to go out in public or to a meal, because they don’t want to constantly be wiping drool. patient reported outcome measures, tools, problems, they are considered the gold standard for assessing the patients experiences and their perspectives and how we should be using them in our clinical practice and research. The patient, I always say you’re the expert, you know you better than anybody. So tell me how we can help you. And so using these patient reported outcomes is something I’m doing a lot in my practice.
Megan Berg 29:05
This feels like it like an uninformed question for me. But I think a lot of people feel intimidated or overwhelmed by patient reported outcome measures. It’s like okay, where do I find those? Do I have to subscribe to a journal to get access to them when they’re published? In my I guess I just assumed that like we can all create our own patient reported outcome measures, correct?
Stephanie Henigin 29:31
Yeah. I mean, it’s just more of you asking questions. And it’s, it could you could consider it like a motivational interview to you’re just asking questions and getting information from the patient. My understanding and maybe I’m wrong, but it doesn’t have to be standardized because every patient is unique. Every person is unique. So I think it’d be hard to have a standardized set of patient reported outcomes.
Megan Berg 29:59
It can be standardized to the patient. So like if you’re asking them on a scale of one to 10. One being doesn’t affect me at all. And 10 is like, I can’t live my life because of this barrier, like how much does it affect your life? And they say what’s on the scale? And then you could ask that same question two weeks in or a month in or whatever. And you’re moving on, hopefully moving along that scale. So it’s standardized to that person. And you’re able to definitely changing but I don’t think it has to be something that’s published or, yeah, standardized to a whole group of people, we can all create our own patient reported outcome measurement tools. And if anyone has any other information, as you’re listening to this, that we could share on that topic, that would be great. Because it’s something that I, I really like to use those and, and there are really good ones out there that have been published. So I don’t want to imply that those aren’t out there. But we can also create our own. So thanks for letting me jump in.
Stephanie Henigin 30:58
Yeah, that’s something I would love to do in the future is to kind of create some more patient reported outcome measures like informal ones, just to kind of guide you know that beginning that but I don’t want people to just say, well, these are the only questions I can ask. It’s, it’s a conversation. So it’s in the back of my mind of things I’d like to do in the future. Um, some other ones that they talked about the the international Parkinson’s movement and disorder society, in this article is this manic review looked at the ones that are available, and they found that the RAD bound oral motor inventory for Parkinson’s disease was the only tool that kind of met their criteria for clinical use. And this one is free for speech therapists to access. So that’s good. And then that the red bound does have three subsections that address speech swallowing and saliva. It which then breaks down into like the physical frequency, how often are you drooling? And those psycho psycho psycho social impacts? So, how do you feel when you have that drooling? Is it affecting your social relationships, and whatnot, so just again, opens that door to have this conversation with the patient and their family. Excellent, thank you.
Megan Berg 32:28
Okay, we’ll move on to our fourth new resource. And this is all about spaced retrieval, written by Jennifer and I think she’ll introduce it. And we’ll do a little bit of a roleplay. So you can see how it works.
Jennifer Leger 32:41
Yes, so spaced retrieval is an evidence based memory technique that I’ve used in cognitive rehab. With my patients following brain injury, it’s been more studied with individuals with dementia, but it can be used with others who have difficulty in remembering information. A lot of times, I’m using this with my patients, as they’re, you know, trying to remember important information that they need to know while in the hospital to keep them safe. And I’ll kind of talk about some functional and meaningful targets that we can choose here in a minute. So research has shown that individuals with kind of mild to moderate dementia have shown the ability to learn new information using this technique. So it’s kind of interesting, it uses something called procedural memory. So this is a type of memory where you can complete a task without really consciously thinking about it. So some tasks you might think about that you do that you don’t really think about. It’s like tying your shoes or riding a bike, feeding yourself, you’re not really consciously thinking about all the actions that are involved in doing that, we just do it. And so it uses that type of memory to help these individuals learn new information that’s, you know, functional for them. So, like I mentioned, it’s really important to always kind of pick, you know, functional and meaningful targets. So, for these type of patients, thinking about compensatory strategies that you’re wanting them to use, you know, that could be related to swallowing, or it could be related to cognition. Precautions, you know, did they just have a surgery and they need to follow you know, hip precautions. Steps First, safely transferring from bed to wheelchair, wheelchair to bed, names of caregivers that are commonly around them, and again, just kind of use of external aids. And so the steps to complete space retrieval as far as kind of choosing that functional and meaningful target. Second is then asking a question to elicit a target response. So in just a minute, we are going to kind of roleplay using spaced retrieval and my question is going To be kind of how do you keep yourself from coughing during meals. So this might be me working with a patient on remembering a specific swallowing strategy that they need to use to be safe during mealtime. And so it always recommends that, you know, you want the person to verbalize the response, but also add an action in with it if that is applicable. So for this one, that response might be either take one single set, and then having the patient take one single step, so say it and then also do that action. And so typically, you start at kind of 15 second interval. If the person gets it correct, you double that time. And then ask the question again, and continue to double the time until they do not get it correct. If they do not get it correct, the first time, you’ll try that 15 seconds. Again, if they do not get it, right, the second time, after 15 seconds, you know, this might not be the best memory technique to use with them. And so we’ll just kind of give a little example of how this might be used, using that target that I had just mentioned. So I’m gonna get my timer out. Right, so I’m here working with Meghan. So Megan, we’ve been working on, you know, you remembering how to be safe during meals. I know that you do not like coughing when you’re drinking. And so how do you keep yourself safe? Or how do you keep yourself from coughing during meals? I don’t know. So, we’ve been working on taking one single sip. So what are we working on?
Megan Berg 36:56
Taking one single sip?
Jennifer Leger 36:57
Yes. Can you show me how you take one single sip from your drink? Good. All right. So just kind of on the back end, I am setting a timer for 15 seconds. And we’re gonna ask that question again. At the end of that 15 seconds. A lot of times I’m doing other things during this time interval, especially once it gets to a longer interval. Okay. Megan, how do you keep yourself from coughing during meals?
Megan Berg 37:35
Take one single sip.
Jennifer Leger 37:40
Yes, that’s exactly right. Great job. All right, so I’m gonna increase the interval double that time now. So we’re gonna go to 30 seconds. I’m starting that timer. So a lot of times, you know, we’re working on other skills, even like, alternating attention back and forth. Because you know, you don’t just want to sit there and kind of stare at each other during this timeframe, you can be working on other goals. While every so often you’re asking that question to elicit the response. Please, second.
Jennifer Leger 38:22
Again, how do you keep yourself from coughing during meals? I don’t know. Take one single sip. One. Yep. Good. Okay, so um, because she did not get that one correct. I would repeat that time interval. So I would do 30 seconds again. And so then you just kind of continue that same order, whether you repeat the time interval or double if they get it correct.
Megan Berg 38:58
Sorry, I had not been taking a sip while doing it. If you’re listening to the podcast, I was taking a sip while I was answering correctly, would you cue the person to go ahead and do that?
Jennifer Leger 39:08
Yes, I would. Because you know, this is really about kind of pairing that action with the verbal response to helps them kind of remember that information. And so I would cue the person to make sure they’re pairing that action with that verbal response. Like, Have either of you use this at all in your treatment?
Megan Berg 39:34
I have. It’s, it’s really fun to see like immediate progress. I gotta say, yeah, it works.
Stephanie Henigin 39:42
No, I haven’t been using this at all. I feel like I’m also an outpatient. So this would be a really good acute care thing, I think.
Jennifer Leger 39:51
Right? Right. I agree. I was gonna say I feel like early on in the recovery. I use this more than the outpatient setting.
Megan Berg 40:02
Great, thank you. Okay, we’re gonna move on to our last new resource this month, which is a deductive reasoning puzzle about the storage area. Stephanie wrote this piece.
Stephanie Henigin 40:15
Yes. So these have been requested a lot of these kinds of deductive reasoning puzzles. And before I kind of dive in, I know we were kind of having this discussion before about kind of the idea of worksheets, right. And I just read the in cog, 2.0 updated ones that were were released last month. And for moderate to severe brain injury, they really aren’t encouraging any, like decontextualized tasks that like worksheets, or like computer games, or things like that, for attention, or processing speed. So I know the worksheet is quite a debate in the speech therapy world as it should be, you know, we all always should be kind of reevaluating what we’re doing and why we’re doing things. For me, I do sometimes use deductive reasoning puzzles, because I work with a lot of people who’ve had a brain injury or a stroke. And their main goal is I just want to get back to work. But it’s hard because you know, they’re not working, they don’t really have an ability to kind of grab tasks that they’re doing at that job. So sometimes I do go to these kind of deductive reasoning puzzles, and really just kind of stress. Okay, is this something you’re interested in? If absolutely no, then you know, we’re going to do something different. But this is a way for me to kind of see those higher level executive function skills. And we talk about, you know, the point of this is not to get it, right. Yes, it’s great if we get it, right. But the point is for you to kind of learn how you’re processing through this now. And that’s why I love deductive reasoning puzzles, because it’s, it is hard, and you have to infer from the language, the answers are not given to you, you have to use the information that you have in the table to kind of make the best guess. And unfortunately, we can’t replicate that work. So just kind of doing the best we can to use these skills within a speech therapy room. So I personally really enjoy them. And I have a lot of patients that do. But I also have patients who were like, Yeah, I don’t get it. It’s not for me, so I fully respect all of it.
Megan Berg 42:41
Yeah, and I’ll I used one of these the other day with a patient, and they were on a new medicine regimen. And so they’ve struggled with a lot of cognitive issues their whole life. And I, I’m sure there’s like maybe some dyslexia learning differences in there as well. But they were on this new medicine regimen. And this is like they asked specifically to work on deductive reasoning things. And their job is definitely not something we could recreate in a therapy environment. And the level of confidence boost that I saw was really cool, just in the sense that they kept saying, like, I never could have done anything like this before. And so for them, it was meaningful in that it’s a complex cognitive task, they couldn’t do it before something has changed in their stay with their medicine, and now they can and so that opens the door to talk about, okay, like what else has been challenging in your life, that you could now possibly approach and let’s talk about those things. So always kind of bringing it back to the context of their life, and like you’re saying, being really specific about why we’re doing this. And then also will say that the pictures never match the solution. So that’s something that has come up a few times, where patients will say, Oh, I thought I thought that’s where that went, because that’s where it was in the picture. So I would recommend either folding it over so that they’re not distracted by that, or letting them know, it, you know, it doesn’t match.
Jennifer Leger 44:14
So yeah, I was gonna jump in and just say that, I like that, you know, we have a variety of these now, too, because I think that does help tailor it to the patient. So somebody who, you know, we have one about kind of garage door, somebody who really enjoys working in their garage and working with their tools, you know, thinking about where the best places to put them and, you know, maybe the things that are on the bottom shelf, or the things that you use most frequently, and also kind of coming back to maybe new impairments and how that’s going to affect their ability to, you know, navigate their, their garage, and so I think, even though it might not be directly related to their work or something like that it might be related. Do something that they enjoy. And we can still kind of tailor it to some of those interests and hobbies.
Stephanie Henigin 45:08
Yeah, I agree. And you’re right, you can kind of piggyback on this. And maybe they, they aren’t interested in this task, but and then maybe you can say, Well, explain to me how do you set up your xyz, and then it can become a language task. And then kind of talking you through? Well, I put my paint supplies up on the top shelf, because I don’t touch that very often, I don’t have to paint too much. So there’s lots of ways to use this. I also use this a lot for people who’ve had like a concussion or brain injury. And we’re trying to practice the skills or knowing maybe when to take a break. Like, if this is a lot of concentration, and they’re starting to get a headache, we talk a lot about the rule of two. So trying, if you’re starting this at a one out of 10, for pain, and then you’re doing this for a little bit, and now you’re at a three out of 10 for pain, I want you to kind of advocate for yourself, hey, I’m getting I’m getting to that two point, I need to take a break. And so I use this a lot for just practicing that skill to of knowing not to push through when you need to take a break, or crossing off clues and stuff like that to visually eliminate things.
Stephanie Henigin 46:37
I was like, Do you want me to actually talk about this resource? Or is it was more of just kind of talking about how I would use it?
Megan Berg 46:44
Yeah, I mean, I think it’s self explanatory. Yeah. But at the end of the day, at the end of the session, like just always checking in and making sure like, Is this helpful for you? Like, is there anything else that we can do that would be more functional? Instead of just like, Okay, I have 30 seconds to prepare. Like, I know, we’re working on executive functioning skills. I’m just gonna grab a deductive reasoning puzzle, because it’s quick, I think, just always step back and think about what’s the most functional approach first.
Stephanie Henigin 47:19
Yeah. I always start my session and just have a couple options. And I first asked him, like, what do you want to work on today, and then I have some ideas, but I always like to ask, and then we kind of go from there. Great.
Megan Berg 47:35
Okay, we’re gonna move on and wrap up with our case study. So like I said, this will be a chance for us to talk about different clinical perspectives and ideas, as well as resources that are in our library that had been in her library for a long time. So I’m gonna read this out loud. For anyone listening on podcast, our case study is about a 71 year old female who had a stroke with dysphasia, characterized by delayed swallow with trace aspiration present on video. But she hasn’t developed any pneumonia since the stroke about nine days ago. It was recommended to drink nectar thick liquids by acute care SLP. But she’s been going against this advice, and is now on your caseload in inpatient rehab, so she had a stroke, she had a swallow study and acute care. She’s now moved to inpatient rehab, and she’s going against the advice of nectar thick liquids.
Megan Berg 48:32
And I’ll start with a resource that popped into my mind, this is one that I use a lot based on the work of John Ashford and many others at this point. And it’s the three pillars of aspiration pneumonia. And I like this handout, because it’s very easy to read, we can talk about the three different factors of oral health and the presence of respiration, and the immune system status. And then we can talk about which one of those factors are in our control and which one is out of our control. And so if we can maintain good oral health for this patient, and maintain a strong immune system, which may not be possible in the context of recovering from stroke, then we would have no risk of developing aspiration pneumonia, even with the presence of desperation. But this is just a good chance to be able to talk about all the different variables that go into that risk, and facilitate Patient Decision like informed decision making about the risk, the level of risk that they want to take with their choices. And I think, ultimately, I always have an approach of it’s like, it’s whatever the patient wants, and the more that we can educate, the better. But I think there’s a fine line to between like, over educating and saying things like, okay, like it’s your life, do whatever you want, versus providing really solid, cohesive education and then stepping back and honoring their choice. So yeah, that’s the resource that I would choose for this case study. And I just threw this up here. For anybody who’s interested in learning more about those three pillars. This is the classic paper that everybody refers to by John Ashford, it’s called pneumonia factors beyond aspiration, it’s an perspectives on swallowing and swallowing disorders. And it’s available on Asha wire. So if you’re an ASHA member, you should be able to access it as long as you’re logged in. And Stephanie, what resource did you pick for this case study,
Stephanie Henigin 50:43
I picked a more recent resource, we have to kind of determining that risk of aspiration. This is more geared towards the speech therapist. Because I love the three pillars. I use that a lot, too. But this one dives a little bit deeper in for the speech therapist to consider the person kind of as a whole. And, again, I do think it matters whether or not you’re an acute therapist, inpatient or outpatient therapist, because you’re going to be dealing with different things on this list. So it talks about medical conditions, oral care, their activities of daily living, if they’re if there’s kind of any tubes or anything, or a ventilation, kind of the bolus itself, is it like a thicker liquid or acidic? Does that person take fast, fast eating with large bites? And then just kind of considering the person’s general health? And it’s this yes, and no, kind of you go through it. And if there’s a yes, the person could have an increased risk, if there’s an ill they have a decreased risk. So when I do swallow studies in outpatient i, this is what I’m going through in my head to kind of see, well, if they’re coming to me an outpatient, I’m seeing them aspirate. But I mean, they’re living at home safely, their bodies, respiratory system is safely able to kind of protect itself, their risk of aspiration is probably lower than someone I’m seeing in acute care, who they can’t really they cognitively that’s affected because they very acute, they can’t maybe follow strategies as well. So I find this really helpful to kind of consider as a speech therapist. Yeah, Jennifer, do you ever use this?
Megan Berg 52:37
Oh, she’s muted. Oh, oh, can you hear us? Jennifer? You’re muted. Yeah.
Jennifer Leger 52:49
Sorry about that. But I was just saying, yes, it’s, it’s mainly in my head as a checklist. But yes, I frequently go through kind of all of these different areas to assess kind of risk of aspiration. And as well as thinking kind of going back to the case study, you know, sometimes you want to know more information, and, you know, how is their cough responses? Are they mobile, like all of that, you know, definitely goes into the decisions that you make. And so I think it’s helpful to just see this and helpful for kind of new clinicians or students, too.
Stephanie Henigin 53:22
Yeah, and I think it’s important to realize that even healthy adults, they they have trace amounts of aspiration of food and liquids and saliva, but they’re able to protect their their airway because of how the respiratory system is built. So it’s just we need to think about the big picture a little bit more, instead of just up they aspirated. Let’s, let’s click on their liquid.
Megan Berg 53:48
Yeah, and when you wrote this resource, I was like, is there like a score is like each one worth a point or something. And that’s not how this resource works. And I think it it’s more like you’re saying guiding clinical decision making. And I think it’s a really great resource for anyone who’s new to documentation, because it has all of the kind of keywords that you want to include right there for you.
Stephanie Henigin 54:12
Yeah exactly. Put all your documentation to use and write in why you’re recommending them to have been liquids from another aspirating. You could say they have good health, they’re, they’re able to really active, they’re mobile, they’re able to do all these other things. And that’s why I’m saying they’re safe drinking regular liquids.
Megan Berg 54:34
Great. And I can’t remember if I named this piece out loud, but for people listening on the podcast, this is called Determining the Risk of Aspiration.
Jennifer Leger 54:43
And the last resource we have for you related to this case study is chosen by Jennifer and it is called Oral Care and Aspiration Pneumonia. So this is kind of an older resource and this one’s I feel like more kind of written for the patient. And so just kind of for further explaining just the importance of oral care and how, you know, the risk of acquiring aspiration pneumonia is higher individuals with poor oral health. Again, just going over kind of some of the statistics behind that, as well as given some information about signs of poor oral hygiene, such as you know, pack white patches on the tongue, dry chapped lips, bad breath. So just kind of helps the person to, you know, reflect back on themselves and think about, you know, do I have any of the signs of poor oral health? And what can I do to kind of improve that specifically with this patient? You know, especially if they want to stay on that.
Megan Berg 55:48
Okay, and then at the end of each episode, I’m going to let everybody know about resources that have been released into the library by other teams, including the OT team and the PT team. So the OT team recently created a resource called emergency preparedness with a disability. And it’s a really great resource if you’re working on functional problem solving, as people go home. And so it talks about emergencies that you have at home emergencies in the community and natural disasters, and then helps guide everybody through making an emergency plan, talking about any assistive devices that are needed, mobility impairments, cognitive impairments, things like that. And the OT team also came out with a handout all about growth mindset. And it just is a basic handout for patients who maybe are working with a fixed mindset where they’re thinking, I can’t do this, it’s too hard. I give up I’m making too many mistakes, that kind of mindset. And talking about shifting towards a growth mindset where the thoughts are more circling around things like I’m still learning, I’ll keep trying, this is going to take time and effort, I’ll try a different way. So definitely a great resource for people with a brain injury.
Megan Berg 57:18
And the physical therapy team came out with a handout about frontotemporal dementia. So it talks about the basics, who it affects, and then the three different variants. So that could work well as the patient and family education handout. And you can find all of the resources that we talked about on this episode at therapyinsights.com. If you’re an Access Pass subscriber and have the printables feature activated, you can go ahead and print any of those resources right away and use them in your sessions. If you’re not a member, you can sign up at therapyinsights.com. We’re going to have all of the links available in the show notes. So if you want to check out the show notes for the podcast or YouTube, you can find those pretty quickly. And we are taking requests for any questions you have for our team. If you have a case that you want us to talk about, if you have a situation or a scenario where you want us to list the different resources that we would use in that situation, you can reach us at support at therapyinsights.com. And we’ll be back with a new episode dropping on April 1 With all of the new releases for April. And so we will see you then thank you so much for spending this hour with us. And thank you to all the therapists out there who are working to make therapy informed, empowered in person centered. So we’ll see you next time. Thanks everybody. Bye!