under the belt

This week I got a few new experiences under the belt.

First, I and another clinician have been providing Lee Silverman Voice Treatment (LSVT) therapy to a 60-something client with Parkinson's disease. LSVT is THE speech therapy for individuals with PD and one of the only therapies in our field with such high levels of evidence supporting it. It truly is amazing. Not only were we delivering this therapy, but we were being supervised by the creator of it (who is also one of my current professors). It seems she doesn't usually do clinical supervision in our clinic, so this was a unique opportunity -- and one you can bet I was pretty nervous about. I was also nervous because I don't think of myself as having an "LSVT personality," in which you are a super excited cheerleader and also a boss of the session and client. However, it went very well. BUT, the specific experience this week that was a first for me was that we had to dismiss our client. LSVT is very regimented and requires treatment fidelity to be effective. Part of the therapy is homework -- daily on the days you receive treatment (four days per week) and twice daily on the days you don't (the other three days of the week). Our client was not doing homework. It was a tough thing to dismiss: Sure, it was too bad I didn't get the full experience of the therapy and seeing the results and getting those therapy hours, but more than that, I felt bad for the client. It kind of feels like sending the message, "You failed" (which I know is not true). Plus, I had built up a relationship with this client and all of a sudden I was saying, "Sorry, I'm not going to help you anymore." Sad. I don't disagree that it was the right thing to do. I hope the client will find a time in life when he can commit to the therapy and comes back and does it!

Second, I performed my first real bedside swallow evaluation on a real life hospital patient yesterday! The patient came in with suspected stroke due to right-side weakness and some decreased ability to talk, which was then exacerbated by a fall onto a hard surface (so likely post-concussive as well). Imaging did not confirm stroke, but a swallow study is always in order for suspected stroke because cranial nerves can be damaged, impacting your motor and/or sensory functions -- both of which are very important for swallowing. As you might imagine, the subfield of swallowing in speech-language pathology is a very important one -- it's probably the only one in which your decisions could result in the death of the patient. Yikes. The goal is to determine whether the patient is safe for swallowing, and what types of textures or strategies might facilitate safety. Safety is does not just mean eating without choking; what you really want to be concerned about is aspiration (food or liquid going down the trachea into the lungs) because this can cause aspiration pneumonia and subsequently death. AND aspiration can be silent! That is, the patient does not react to food/liquid slipping down past the vocal folds with coughing -- it just goes down. Aspiration can not be confirmed with a bedside swallow evaluation; a video fluoroscopy swallow study is used for that, in which you actually watch by way of X-ray video barium boluses being swallowed and can see it going down the wrong way. But anyway, I did the bedside eval, which looks at swallow structure structure and function (including strength and range of movement) and sensation. We then provide different consistencies to the patient and observe swallowing, while also feeling on the neck for proper movement of the larynx. Yes, I was nervous. Yes, I forgot some things or did not fully do some things (no worries -- my SLP supervisor was right there helping me out). I got lucky that my patient has no dysphagia / no risk of aspiration. Yay, patient!