Friday, September 29, 2006


I don't have many pet peeves related to aphasia. (The vast majority of my SLP pet peeves are related to dysphagia). But there are a few comments that never fail to irk me regarding aphasia.

* "He (or she) needs a communication board" -- usually said regarding a patient with severe aphasia. Because aphasia (an acquired language disorder) affects ALL language modalities to some extent -- speaking, listening, reading and writing -- a patient with aphasia severe enough to markedly impair verbal communication is usually unable to spell out words, either by writing or by using an alphabet board. A few can use a picture board to point out what they want or need, but I can count on one hand the number of patients I've had that could do that reliably without needing a significant amount of training.

* (In a doctor's note): "Patient is severely aphasic but understands and writes without difficulty." Well, either the comprehension and writing tasks weren't difficult enough to show higher-level impairments, or else the patient isn't aphasic at all. Again, aphasia affects ALL language modalities. Some modalities may be more impaired than others (for instance, receptive language -- reading and auditory comprehension -- may be relatively preserved compared with expressive language -- writing and speaking), but the patient will have some deficits in all areas. Despite frequent attempts at education, I still have doctors/nurses/PTs/OTs/etc. saying to me, “I think Mr./Mrs. So-and-so may have some receptive aphasia too,” in a tone implying that it’s something unusual and a “good catch” to have been realized, or else looking at me in surprise when I say that the patient with severe Broca’s aphasia does NOT have normal comprehension. And what about the patient with documented “aphasia” all over the chart, who really isn’t aphasic at all? How does that happen? In one such case in a nutshell, dysarthria so severe that the patient was nearly anarthric (consonant sounds /m/ and /h/ and shwa vowel comprising the entire phonetic inventory), combined with residents who apparently did not read the speech pathologist’s daily progress notes stating, “patient is NOT aphasic, patient has severe dysarthria.”

* "He (or she) has expressive aphasia." Well, simple enough, and often true; so why does it bother me? Because, at least where I work, this phrase represents the reduction of aphasia to a simple dichotomy: expressive/receptive. A patient has trouble talking? That’s expressive aphasia. They don’t understand what you say? That’s receptive aphasia. Never mind that by these definitions, every single aphasic person would have “expressive aphasia,” since word-finding difficulties must be present to make a diagnosis of aphasia. And what about, say, a severe Wernicke’s aphasia? Clearly that would be “severe receptive aphasia,” but then how are you supposed to label the resulting word salad that comprises the patient‘s expressive communication? Moderate? Severe? Moderate to severe? If you can’t understand anything the patient says due to all the neologisms and paragrammatisms, that would make them severe, right? But they’re fluent, so doesn’t that count for something? Hmph. Personally, I’m a big fan of classifying aphasias into the aphasic syndromes (anomic, Broca‘s, Wernicke‘s, transcortical motor, transcortical sensory, conduction, and assorted subcortical aphasias). The syndromes are shorthand for conveying a constellation of symptoms. Of course, not every aphasia you run into fits neatly into a syndrome. And not everyone, especially non-SLPs, knows what the syndromes are -- so I usually wind up doing all sorts of verbal gymnastics to be as clear as possible. But overall, I think that labelling clear-cut aphasic syndromes as such conveys a lot more information than a simple “expressive” or “receptive”.

Sunday, September 24, 2006


VitalStim Therapy is a type of NMES (neuromuscular electrical stimulation, or e-stim) specifically for swallowing. Patterened after the electrical stimulation used by physical therapists for improving muscle function in the extremities, it is a relative newcomer to the field of dysphagia therapy. Currently, there is not a lot of research to support its use (although there are a number of studies in progress), but anecdotal evidence of remarkable improvements in swallowing function in a relatively short amount of time abounds. E-stim is currently one of the most controversial topics among speech pathologists, with a split between those who hesitate to use an unproven technique with little supporting research to date, and those who want another technique in the "bag of tricks," research or no research.

My take on VitalStim? I think it has potential. I think it certainly deserves further study. I think there is probably something to at least some of the anecdotal reports (besides spontaneous recovery). However, I also think that, at least in some cases, there is a placebo effect, both for the patient who expects it to cause drastic improvements, as well as for the clinician who expects to see remarkable change. That said, if I were in a position to do so, I would likely become "certified" and offer it as an option to some of my patients on an experimental basis, with patients informed that it was still unproven, and I would keep careful records of all those on whom I trialed it -- more or less my own clinical trials.

With that said, I do not like how it has been marketed. At all. It seems to me that it was rushed to market with only one (very poorly done) study to back its use. Much of its support comes in the form of anecdotes. The general message from its proponents seems to be, "Everybody start using it now! Better evidence of efficacy will come along later." I think a lot of statements made about it are misleading or poorly informed. Just about everybody (with dysphagia) is a candidate, according to proponents, and it helps just about everyone improve (~98% is the oft-quoted number). The “contraindications” are laughable.

Now, none of these criticisms are reasons to completely discount the modality as a potential asset to dysphagia therapy, but they do indicate the need for critical thinking and honesty with patients. I’m sure I’ll be blogging quite a bit about VitalStim, since it’s such a hot topic currently, and also because the debate over it relates to a number of underlying issues in swallowing disorders and speech pathology in general.

Friday, September 15, 2006

"But she aspirated!"

A few months ago, I got an order for a bedside swallowing evaluation on an elderly woman who was admitted with pneumonia. Her doctor wanted to rule out aspiration -- of food or liquids -- as the cause of the pneumonia (a whole 'nother issue I won't go into now), so he ordered the eval.

Practically shouting (so much for HIPAA when you have a very hard-of-hearing patient!), I asked if she had trouble swallowing. No, no trouble at all, she answered, looking at me like I'd just asked her something outrageous. I explained the reason the doctor ordered the evaluation, then continued with my questioning. Do you ever cough or choke with meals? Have trouble chewing your food? Does food ever feel stuck? Does food or liquid ever "go down the wrong pipe"? No, no, no, and no, she replied. Her oral motor exam was negative. No neuro signs. Swallowing looked okay. Good oral control. Adequate hyolaryngeal movement. A timely swallow. No signs/symptoms of aspiration -- no coughing, throat clearing, change in vocal quality, nothing. "Oral/pharyngeal swallow appears WFL," I wrote on my report, and recommended continuing her current diet, regular food with thin liquids. (Now, I can just hear some speech pathology types muttering, "but what if she's silently aspirating? Shouldn't you do a videofluoroscopic swallowing study (VFSS)?" See my thoughts here).

The next day after the bedside eval, I got a VFSS order for the patient. "I still think she's aspirating," he wrote in his progress note. So I did the video.

Her swallow was picture-perfect. Coordinated, good airway protection, no penetration (entrance of contrast into the laryngeal vestibule, but above the level of the vocal cords), no aspiration . . . except for on the very first swallow, with thin liquid barium. With that swallow, she was just a little discoordinated (possibly due to the initial tasting of the barium, or to being not quite prepared for that first sip), and she aspirated a trace amount, barely a drop, to just below the vocal cords. It wasn't there for long, as she had an immediate coughing fit which promptly expelled that tiny drop of barium from her airway. She coughed and coughed and coughed some more before we could continue with the study. I certainly didn't need to worry about silent aspiration with her! Every other swallow on the study was perfect, including several more with thin liquids. Given the absence of coughing fits during her bedside eval, I was confident that the aspiration on the video was just a fluke. And, at any rate, the aspiration of a trace amount of liquid which was immediately cleared from the airway with a strong cough would not be contributing to her pneumonia.

So I dutifully recorded the events of the video in my report, along with my impressions of an oral/pharyngeal swallow WFL (yes, despite the aspiration, as that was an isolated incident which can happen even to someone with a completely normal swallow) and a recommendation to continue regular consistency foods and thin liquids. When the doctor saw the report, he flipped. "But she aspirated! How can you recommend thin liquids?! That's what she aspirated!" No amount of explaining -- about the discrepancy between the bedside eval and the VFSS, the strong cough and good airway protection, the lack of a cough (and, by extension, lack of aspiration) on bedside evaluation, the far greater risks of thickened liquids as opposed to thin liquids for this patient -- nothing could sway him. He looked me up and down as though appalled that I would dare to suggest continuing a regular diet when the patient clearly aspirated on the VFSS, unmoved by my reasoning, my evidence, my suggestions. And then he changed the patient's diet to pureed with nectar consistency liquids. And changed her diagnosis from "community-acquired pneumonia" to "aspiration pneumonia." Never mind the fact that unnecessarily putting the patient on a modified diet and thickened liquids would greatly increase her risk of malnutrition and dehydration, and that those risks were far, far greater than the minimal, if any, risk from rare trace aspiration with an intact cough response. Argh.

And whatever happened to the patient? I called the nursing home speech pathologist when the patient was discharged and told her what had happened and what my recommendations were. She evaluated the patient at bedside. When I saw the patient on a subsequent admission (not for pneumonia, still with a swallow WFL, this time with a different attending doctor), she had been switched back to a regular diet with thin liquids at the nursing home. Thankfully.

Wednesday, September 13, 2006

Huh? Where'd That Come From?

I came across a short article the other day, written by a speech pathologist. At one point the author listed signs of aspiration: "Coughing, throat clearing, wet 'gurgly' voice, respiration changes, watery eyes and nose, and widening of the eyes are all indicators of aspiration." Okay, the coughing, throat clearing, gurgly voice, and respiration changes I agree with. The watery eyes and nose, if bilateral and accompanied by a cough. (Unilateral eye tearing or nose running is something else entirely. It MAY be associated with deficits which can cause aspiration, but is not a sign of aspiration in and of itself.)

But the last one in the list? "Widening of the eyes"? Where on earth did that come from? I have never heard that one before as a sign of aspiration. I don't even see how that could even be related. Unless, of course, it's part of the shocked/panicked expression a person gets when they realize they're choking... (but even then, it would hardly be the most salient detail -- the sudden apnea, cyanosis, inability to speak, and possible collapse would probably be slightly more obvious symptoms in such a situation, don‘t you think?!)

Huh. Well, either the canonical “Signs/symptoms of aspiration” list expanded when I wasn’t looking, or else the Dysphagia Myth Generator has been working overtime. (I’m guessing the latter).

If It Quacks Like a Duck . . .

Hypothetically speaking, suppose there were a treatment technique that had been around for several years. And this particular technique reportedly helped lots of patients. And the professional organization for the practitioners who could use the technique offered CEU's to take the class to become "certified" in the technique. And those who had taken the course said that the theory behind the technique "seemed sound." But. . .
  • There was no published efficacy data despite frequent hints at forthcoming research
  • There was no published summary of the technique and rationale for it
  • The only way to get comprehensive information about the technique was to take the (pricey) "certification" course
  • All the proceeds from that course went to one person/company (the originator of the technique)
  • What was known about the technique and its theory did not correspond with any known physiologic principles

Then what would you think? At what point do we as professionals discount a technique that apparently has promising anecdotal evidence but no true efficacy data (not to mention lack of sound theory) behind it?

Monday, September 11, 2006

Silent Aspiration

If you ever want to induce paranoia in a speech pathologist who treats swallowing disorders, mention the term "silent aspiration." It is generally regarded as an ever-present possibility with potentially disasterous consequences if not immediately recognized and treated appropriately.

So what is it? Silent aspiration is variously defined as aspiration without any signs or symptoms whatsoever, aspiration without a cough, or aspiration without an immediate cough. I have seen some doctors use the term referring to aspiration of small amounts of refluxed gastric contents without obvious symptoms. I tend to avoid using the term because it can be so unclear. What if a patient aspirates but doesn't cough until several minutes later? Is it still silent aspiration? Even though the aspiration did eventually trigger a cough? What about a patient who only clears his or her throat in response to aspiration? Or who has a change in vocal quality, but no cough? Is that "silent"? In the interest of clarity, I tend to just describe a patient's response to aspiration -- or lack thereof.

My thoughts on silent aspiration:

The possibility of silent aspiration is often given as one reason (among many) for performing an instrumental assessment -- usually a videofluroscopic swallowing study (VFSS) -- in every patient in whom pharyngeal dysphagia is suspected, or in some cases even a remote possibility. I don't do this. In many cases I think it's overkill and a waste of resources that won't yield any additional information beyond what was already obtained during the bedside (clinical) swallowing evaluation. Now, I certainly do request videos at times, and in some cases I may even insist on them; but I do not routinely perform them on every case of pharyngeal dysphagia that comes down the pike.

And why not? Well, aside from the fact that a VFSS does NOT show what happens when a patient is eating a meal, I don't believe that silent aspiration is nearly as common as is often supposed. Although some studies have put the number as high as 60%, I have several reservations: (1) What quantity was being aspirated? Just because a patient doesn't cough with trace aspiration to just below the vocal cords doesn't mean that they won't cough if a larger amount is aspirated; (2) How long after the aspiration was the patient observed for cough or other symptoms?; and (3) What were the patients' diagnoses? Some disorders are more likely to produce impaired sensation that can lead to "silent" aspiration. Was sensation tested during the bedside eval before the video?

In addition, there is no indication that all "silent aspiration" is clinically significant, especially in smaller quantities. Patients who do not cough with aspiration are somewhat more likely to develop pneumonia, but there's still not a one to one relationship between the aspiration and the pneumonia.

And finally, even though a patient may not cough or have other obvious symptoms, this does not mean that it is impossible to determine clinically that a patient is at increased risk for aspiration. People do not just up and aspirate for no reason. Something has to go wrong with the swallow, whether it is decreased coordination, poor hyolaryngeal movement, poor airway protection, and so on -- all of which can be detected clinically. I have never had a patient in whom I had no suspicion of aspiration at bedside aspirate significantly on VFSS (now, granted, I am less likely to request videos on these patients, but I do on occasion, and sometimes a doctor will insist on one.) So, while I recognize that the absence of overt signs of aspiration is a very real possibility, by paying attention to the entire clinical picture, I can keep it from being a surprising occurence.

Why did you become a speech pathologist?

I didn't set out to become an SLP. Growing up, I wanted to be, variously, a:
  • teacher ('til I realized how difficult keeping 20 to 30 kids in line would be);
  • writer (until I realized that length alone did not ensure a quality work of literature, and that my fiction-writing abilities left a whole lot to be desired);
  • veterinarian (until I realized that if I had patients, I would want them to be able to talk to me... the first signs of an SLP bent??);
  • astronaut (until the Challenger explosion);
  • archaeologist (until I realized that male archaeologists do NOT all look like Harrison Ford, and that digging stuff up, while rather romantic-sounding, was only the very beginning of a lot of work interpreting what the dug-up stuff meant);
  • cryptographer (until I realized how much math that requires, and that it wouldn't be nearly as exciting as it sounded); and, finally, a
  • doctor (until I realized how old I would be once I finished med school and residency).

When I started college, I decided to double major in linguistics and an (unrelated) liberal-arts major. I wanted to get a Ph.D. in an esoteric linguistics-related discipline and spend the rest of my working days in an ivory tower of academia, teaching and publishing important-sounding scholarly papers and books. Unfortunately, it eventually dawned on me that there was probably not much of a demand for Ph.D.'s with such an esoteric specialization, and that I would have to move to wherever I was lucky enough to get a job offer, even if it was the last place I wanted to live. I decided I wanted more flexibility. And practicality. A profession in which I could find a job fairly easily, wherever I decided to move. Something I could pick up and put down if/when I decided to have kids. Something linguistics-related.

I started looking at graduate programs in Communication Sciences and Disorders. There weren't a whole lot of other linguistics-related options that met my requirements (except for computational linguistics, which was out of the question since my computer science training/experience was exactly zilch). I found a program that was willing to give me some prerequisite credits for some of my linguistics classes, and allowed me to start taking the undergraduate prerequisite CSD classes simultaneously with some of the graduate level courses. So I signed up.

Initially I wanted to work with kids. Then, after some less-than-stellar experiences in my pediatric practica, I had my final externship in an acute-care hospital. I loved it. I loved reading medical charts, assessing acutely ill patients, doing videofluoroscopic swallowing studies (moving X-Rays of swallowing). I liked doing a lot of evaluations, with a little bit of therapy (treatment) thrown in. I liked seeing almost all adults. I liked the frequent turnover of the caseload and the fact that each day was unpredictable. I liked the variety of diagnoses. I was also afraid that if I started out working with kids, it would be more difficult to switch to working with adults if I ever wanted a change than vice versa. So when I graduated, I applied (and was accepted!) for a job in an acute-care hospital, working with adult inpatients. I've been there ever since.