Hard to Swallow

In my earlier post about a conversation with an M.D. at my facility, I only shared the end of the exchange and the case basics. Here’s how that discussion began:

Hard to Swallow: Morning, doc. So, Patient X.

Doc: Sure, go ahead.

HtS: We got a FEES done on them and it showed a some sort of bulge on their posterior pharyngeal wall.

Doc: A bulge.

HtS: Yeah. We think it might be consistent with cervical osteophytes.

Doc: Wait, go back. What’s a FEES?

I did some quick education, and things ultimately wound up at “Hey, great catch.”

I told you that story so I can tell you this one, about an article from 2009:

Warnecke et al.: Towards a basic endoscopic evaluation of swallowing in acute stroke – identification of salient findings by the inexperienced examiner.

The basic gist is they gave a half hour lecture with lots of videos to some doctors unfamiliar with FEES, and those people did a better job of rating dysphagia severity using a 5-point scale in post-testing than in pre-testing. No big deal. Now take a look at the Subjects section, emphasis mine:

Seventeen neurologists (7 women, 10 men; mean age = 31 years, range 28 to 45 years) with a professional experience of 4.5 years (range 1–16 years) took part in the study. None of the participants had experience with fiberoptic endoscopic dysphagia assessment.

Now, of course we don’t know what “experience” means in this context. But these weren’t just doctors. These were neurologists. Seventeen of them. At least one of whom had been practicing for 16 years. And sure, we don’t know how hard they had to look for these subjects. But they had enough to publish this study.

These are the people who are identifying your patients for you. Sending you referrals. Providing an initial dysphagia diagnosis requiring further evaluation. Tracking your patients post CVA. Giving advice to your community-dwelling patients with Parkinson’s and ALS. And it’s possible they could be described as having no experience with FEES. If they don’t have experioence with one of the two gold standard dysphagia assessments, how much do you think they know about the rest of what you can do for their patients?

[Editor’s Note: In honor of #BHSM, and since #DysphagiaAwareness happens in a couple weeks anyhow, we are foregoing our regularly scheduled programming in favor of a dive into one of our favorite tech-based therapy tools for language, auditory processing, and cognitive-communication, in lieu of our usual swallowing-only MO. Again, we promise not to make a habit of it. If you want a dysphagia-centric app review, there’s one here.]

Tactus Therapy’s Advanced Comprehension Therapy has a deceptive name. Ostensibly, it’s exercises in sentence-level auditory comprehension. In the right hands, this tool addresses not only auditory and reading comprehension, but also syntax skills, visual discrimination, sequencing, immediate recall, and cognitive flexibility.

The app is broken down into three main subheads: Identify, which provides field choices for concept identification at sentence level; Build, a sentence construction task; and Follow, for following directions.

Identify provides sentences of customizable complexity, anywhere from “The woman reads,” to “She is being told a secret by him,” and, “The man is sprayed by the woman.” As I’ve said before, Tactus has always been truly adept at choosing distinct, appropriate, engaging (and sometime eminently memeable) visual stimuli, and the images here are no exception. I personally love to use the pronoun-centric stimuli for my patients who keep keep calling me “ma’am.” Stimuli can be presented written, via built-in text-to-speech generation, or both.

Build is intended as a “copy what you hear” exercise, but I prefer to hit the mute switch and use it as a generative syntax and constraint-based cognitive flexibility task. “You’ve got 5 blanks here, and 8 words. Make a caption for this picture that makes sense.” The complexity of stimulus can be configured here just as it can in “Identify,” and the images come from the same bank. Targets can be dragged to their intended location, or simply tapped in sequential order.

Follow is where I get the most mileage. One-, two-, and three-step directives. Conditional directives. Directives with adjectives. Directives with multiple adjectives. Semantic and syntactical variation in the directives. Auditory stimuli. Written stimuli. I’m not going to say the possibilities are endless, but the possibilities are endless.

This is great for immediate recall and sequencing skills, and—unlike some other rehab-centric app subtasks I’ve used—it provides enough flexibility to use with patients that have a variety of functional barriers. Have trouble with touch-drag skills? Have unaided hearing loss? Have low educational status or limited semantic memory? Bad with spatial concepts? Honey badger Follow don’t care, you can still exercise those sequencing skills.

From an app design perspective, Tactus has really settled on an aesthetic that is modern but not flashy, and they clearly strive to strike a balance between complexity/customizability and simplicity/ease of use.

Animations are snappy and provide a sense of place when navigating through task setup, and then within the tasks, dynamic motion is replaced by subtle fades between stimuli, which are generally appropriately paced for the target patient population. As with all their patient-focused apps, data keeping is straightforward and easily exportable as a PDF via email, or—if you have a relatively modern iPad—via drag and drop/copy-paste from the email screen.

I’ve used this tool extensively since I purchased it, and find it to be tremendously powerful. Still, there are a few things I would love to see in a 2.0:

The option of which order “before/after” directives are presented for 3-step directions in addition to 2-step. 

Use of the system default voice for spoken stimuli. Maybe this isn’t possible with the APIs available (I’m not a programmer, so I don’t know), but I would love to hear Siri reading those sentences rather than Samantha.

Some slightly more semantically complex targets for “Follow,” like the images you’d see in Naming or Comprehension Therapy. I’ve had a number of patients comment “this would be great for kids” or something similar for that task in a way that never occurs with any other Tactus stimuli set, and I suspect it’s the restriction of the directives to the objects that can be displayed effectively in multiple bright colors to accommodate the “+ adjectives” complexity levels. “Before you touch the jumping girl, touch the open envelope” as an option might help to mitigate that.

An option for Build to only play the auditory stimulus when you hit the “repeat” button to allow it to more naturally be partially generative syntax task.

If, like me, you are always looking for ways to replace paper in your cognitive exercise sessions, Advanced Comprehension Therapy is a solid choice. At time of publishing, this—and all of the Tactus apps—are on sale for Better Hearing and Speech Month. They seem to do that every year, but their pricing is usually a pretty good deal even when it’s not on sale, especially when you think about what a WALC book costs. The Tactus library keeps expanding, and Advanced Comprehension Therapy is an excellent addition to any clinical toolbox.

[Editor’s note: This is not the first time we’ve used this site as a platform for whining (whinging for our UK brothers and sisters) about Facebook forum posts, but we promise not to make a habit of it.]

A recent question on the imitable Medical SLP Forum broached the topic, “How much (if any) posterior loss of bolus over the base of the tongue is acceptable?” This question is a lot like my toddler: brash, well-intentioned, only mildly enraging, and able to shed light on biases I didn’t know I had.

First off, the one-two punch of brash/mildly enraging: “(if any)”? Really? Here, I show my age, and state that I can’t even. “Probably plenty” is the response you’re looking for.

Second, well-intentioned: Credit where it’s due, this was posted by a person who is looking at some dang imaging, so we are already well ahead of the curve. Not only that, but they’re asking questions to make their practice better! 🥂

Finally is the real meat and potatoes, biases. Biases come up because I realized over the course of writing a reply to the post that, when left unchecked, my personal EBP Venn Diagram tends to skew exceedingly heavily towards that “evidence” circle. I penned an entire paragraph that can be summed up with Humbert’s Interrogative (“WHAT’S THE PATHOPHYSIOLOGY?”) before it occurred to me, who the heck do we think we are, deciding what’s acceptable?

Ultimately any research and instrumental evidence needs to be held in balance with patient values, goals and expectations. For those of you who haven’t seen the diagram of Evidence Based Practice, I’ve paraphrased my own below.

So the answer to “How much prespill is acceptable?” not only depends on the research regarding normal swallow function, the clinical evidence of safety and efficiency from a given instrumental assessment, and on personal clinical judgment of how much might be too much, but on giving informed consent about the observed impairments to the patient and determining whether and to what degree they value the implications of that impairment for their health and overall function.