Autumn 2002

Articles from the Autumn 2002 Issue

Inclusive communication–coming soon near you?

Money D, Thurman S. (2002)

The white paper “Valuing People” committed speech and language therapy services to the promotion of choice, inclusion, independence and civil rights. This article describes how the Means, Reasons and Opportunities model was developed and used for teaching staff working with people with learning disabilities. Five core roles for the service were identified as: 1. Managing health needs; 2. Making information accessible; 3. Using shared means of communication; 4. Promoting reasons for communication; and 5. Creating opportunities for communication. Developing communication policies and strategies to address these issues was essential for the individual, those in his/her immediate environment, and the local community. The Means, Reasons, Opportunities model was used to introduce the idea of “real-world understanding” to distinguish the differences between verbal and situational understanding, and introduce the concept of functional understanding. This has been used as a framework for inclusive or total communication as part of the communication strategy across Nottinghamshire. The use of inclusive communication is increasingly recognised as best practice and effective use of speech and language therapy services.

A shift of emphasis.

Stanier J. (2002)

This article explores the changing needs of clients with dysphagia associated with incurable head and neck cancer, where patients die slowly with increasing disability from local invasion, obstruction, and progressively distressing symptoms. Although the role of speech and language therapy in rehabilitation of head and neck cancer is well established, its role in end of life care as part of the multidisciplinary team needs developing. Palliative care is part of the continuum of care from diagnosis to death, and as well as the control of pain and symptoms also integrates psychological and spiritual aspects of care and support both to the patient and family during the illness and bereavement. Awareness of the role and perceptions of the patient and carer is of equal importance to clinical management, and this requires tactful discussion and communication. The article discusses the patient’s need for hope, emotional responses, and the quality of life. Issues around the risks and benefits of oral intake and the safety of swallowing are also considered in relation to hydration and nutrition and informed choices. The limits to the speech and language therapist’s role within the multidisciplinary team, ethical considerations, and the need for increased training in palliative care for speech and language therapists are discussed. Two illustrative case reports are provided.

Where do you want to go today?

Cotton S. (2002)

INTACT is a software package with a library of 500 exercise designed specifically for people with aphasia. The software was developed in 1993, and since that time many technological changes in operating systems and computer hardware have taken place. In order to investigate the current usefulness of INTACT, a questionnaire survey of 150 speech and language therapists who had purchased the system was undertaken, of whom 68 (45%) responded. The majority (75%) reported that the software had been installed within a month of purchase, with 12% taking more than a month; 69% had used the software with clients within one a month of purchase; 50% had attended the free training course, and 43% stated that they intended to undertake training. The software was found to be useful in therapy by 74% of those who had used it in this way. Technical problems with the software were experienced by 67% of users, of which half had been resolved, and half were still outstanding. The most common problem was with soundcard incompatibilities. Technical support was considered vital for the software. Although INTACT was considered a brilliant concept by users, there are now too many barriers for its continued use in therapy, and too many modifications would be required to update it. The survey also revealed that although therapists like the concept of using computers in therapy, they need easy access to computers in the clinic, time to try out therapy software, and time for training. Lack of these resources affects the exploitability and effective use of software for treatment. Suggestions for improvements in therapy software are listed.

Unlocking the voice.

Steven L, Thompson J, Brown D. (2002)

Explores the role of physiotherapy in combination with SLT for a specific group of clients with voice disorder due to lack of postural neck mobility. Previous studies have shown the value of osteopathy in this condition, but this is not generally available on the NHS. Following the successful outcome of treating a 70-year-old client with a combination of manual physiotherapy and voice therapy, a pilot study was set up to be conducted over the period of one year. Unfortunately, due to exclusion criteria and withdrawals, the anticipated number of subjects was not achieved and only five patients could be included. This was an insufficient cohort for the study, and so the design was revised to a single case study conducted on a 69-year-old man with a hoarse high-pitched voice, reduced pitch range and intermittent aphonia. Traditional voice therapy procedures were carried out and laryngeal constriction treated by relaxation, retraction of false cords, and use of ingressive airstream. Manual physiotherapy was conducted using Maitland mobilisations to stiff segments as well as advice and exercises to improving general posture and neck posture. Improvements to voice use, quality and production, and to neck status were seen over the course of treatment, although no change had been effected in range of movement, perhaps due to the patient’s osteoarthritis of the neck. A multicentre trial with larger numbers of patients is required to achieve a statistically valid evaluation of the treatment. Until that can be done, the authors believe this is a valuable adjunct to conventional dysphonia therapy for patients who use, and have difficulty in modifying, inappropriate high pitch.

From last to first resort.

Howard S, Hughes C. (2002)

Recruitment and retention difficulties had led to a crisis in Grimsby and Cleethorpes, with lengthy waiting times, poor attendance, unequal service and low staff morale. This article describes how the introduction of a new care pathway has dramatically improved service delivery and improved wating times. The old system had coonsisted of a centralised waiting list following an initial assessment. Under the new three stage system, all children are seen within a 13 week period from referral. Following initial assessment, in stage 1 parents are enabled with an information session focusing on either phonology or language as appropriate, as well as specific activities for home practice. In some caess it is appropriate for parents to attend both sessions. Parents are then asked to sign their child up for a recommended speech and language group (Stage 2) run by a speech and language therapist, or a therapist and assistant, for four to eight children and involve four to six sessions conducted on a weekly basis. On completion, the child is reviewed and may attend another group, repeat the same group if appropriate, or is placed on the waiting list for one-to-one therapy (Stage 3) or may be discharged. Dysfluent children follow a separate pathway. A child identified by a speech and language therapist as having severe and complex difficulties is referred to a third care pathway. Three case examples are provided. An audit of service standards under the new system showed an increase in compliance with standards for improved waiting times to 77%, and a decrease of 25% in non attendance. Staff morale has improved and parental expectations are more in line with the therapist’s.

Getting comfortable with collaboration.

Kersner M, Wright J. (2002)

Speech and language therapists and teachers are learning to work closely together to meet the communication needs of children more effectively. This article describes a study to establish how student speech and language therapists are being prepared for this area of work. The study was in two parts. The first part investigated whether students were aware of joint working practices between their supervising therapists and teachers when on placement in educational settings. The second part investigated the perceptions of new entrants on the first day of their speech and language therapy course to see what they thought about the role of students and the role of therapists when working in schools or special units. All students who responded to the questionnaire indicated that they were aware of joint working practices, and a description of relationships between student, therapist and teacher and sharing of information is detailed. The students did not see liaison with the teacher as part of their role. The second study indicated that although the majority expected to share information with teachers, less than 50% thought that they would plan future work with teachers. The findings are discussed.

How . . . I train others in dysphagia.

One bite or the whole apple?

Broadley-Jackson T. (2002)

A third of residents in nursing homes have dysphagia. Simply teaching nursing staff about eating and swallowing difficulties in isolation has a limited effect, since these are often minor and other factors such as posture, appropriate cutlery, and instruction are the key factors. A two-day course was offered to local nursing homes to enable staff to identify feeding and swallowing problems, initiate actions to remediate problems, and encourage staff to make timely and appropriate referrals. Three questionnaires were given before and after the course, examining knowledge of terminology, clinical knowledge and practice, and an assessment of a video of a role-play. The scores on terminology and awareness improved following training, and staff felt more confident in identifying problems and helping patients. However, the response to the video was poor. No-one identified all eight problems either before or after training, and the collective score was lower after training than before it. This may indicate information overload. On a more positive note, all scored better after training on ways of improving clients’ difficulties, and a checklist has improved overall screening in two of the homes. However the study has raised questions about the impact of training on the short and long-term nursing practice, and the appropriate management of feeding and swallowing difficulties in the nursing home residents.

Read all about it! Fred the Head stops Mars Bars in bed.

Samuels R, Chadwick D. (2002)

In a systematic look at dysphagia training for caregivers, to benefit people with learning difficulties who have feeding and swallowing difficulties, it was found that the more people are involved and understand what is required, the more likely it is that they will do it. Caregivers are provided with sufficient anatomical knowledge to understand why something has gone wrong, using an anatomical model of a cross section of the head with moving epiglottis (Fred the Head) and videofluoroscopy tapes from patients’ case notes showing aspiration. Shared experiences and a risk assessment framework are also used. We are often unaware of how much training is provided and the many different ways in which this is offered, often simultaneously, during visits to clients. Some difficulties are also noted, for example, staff being moved within two months of training, and the attitude of family members. Challenging people’s firmly held beliefs and myths about food and drinks needs sensitive handling, but does need to be achieved if these are detrimental to a patient’s health. A patient only agreed to stop eating Mars bars in bed lying down when the risks had been demonstrated using ‘Fred the Head’.

Consistent with consistencies.

Morrissey N. (2002)

Although the use of thickening fluids is a frequent recommendation for dysphagia management made by speech and language therapists, anecdotal evidence suggests that the majority of patients do not like drinks being thickened, and there is a lack of standardisation across consistencies being prepared. This study aimed to evaluate inter-rater reliability of various consistencies among SLTs, nurses and ward attendants, assess inter-group consensus, identify the need for training, improve the quality of thickened fluids made by staff, and improve patient compliance. Five samples of different consistency were prepared using a commercial thickening agent, Nutilis. Three samples (syrup, semi-solid, and set) were prepared at consistencies as recommended by speech and language therapists, together with two distractors (one too thin, and one too thick). Participants were told that two of the consistencies were acting as distractors, and filled in a questionaire for each sample. The results showed that speech and language therapists were the most consistent in acurately identifying each consistency, and ward attendants were the least accurate. Since the majority of fluids are thickened by ward attendants, this is significant, and highlights the discrepancies that exist between what the SLT recommends and what the patient receives. The findings have led to a training programme for ward attendants to help them understand why the need for standardisation of consistencies is so important.

My top resources.

Woodward S, Davies A. (2002)

The use of patient accessible computer equipment has been integrated into therapy programmes for stroke rehabilitation in North Bristol NHS Trust. Patient accessible computers are available on two stroke rehabilitation wards, and computer equipment is also available for use in the community and group settings.This short article lists computer equipment and software programs that have been found helpful in enabling patients to get started, increase their familiarity with the PC, and programs for speech and language exercises as well as others which are useful extras.