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ISSN 1368-2105

AUTUMN !""!

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Inclusive communication
Coming soon near you?

A shift of emphasis
End of life care

In my experience
No longer INTACT

Student education
Getting comfortable with collaboration

Unlocking the voice

How I train others in dysphagia My Top Resources


Computer software

A role for physios?

Care pathways in Grimsby & Cleethorpes


From last to first resort
R E A L W O R L D U N D E R S T A N D I N G

Autumn 02 speechmag
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Listening Skills Test (LIST)

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Do you need a UK standardised assessment with a difference? The Listening Skills Test looks at four areas: detecting ambiguity in messages, judging utterances about an event, following extended discourse and evaluating verbal statements. Aimed at children from 3;6 to 6;11 years, administration takes 20 to 30 minutes. The normal retail price is 75.91 but the Psychological Corporation is offering a complete LIST kit FREE to a lucky reader of Speech & Language Therapy in Practice. For your chance to win, simply send your name and address marked Speech & Language Therapy in Practice - LIST offer to Liz Akers, The Psychological Corporation, 32 Jamestown Road, London NW1 1YA. The closing date for receipt of entries is 25th October and the winner will be notified by 31st October. LIST is available from The Psychological Corporation, www.tpc-international.com.

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The editor has selected the previous articles you might particularly want to look at if you liked the articles in the Autumn 02 issue of Speech & Language Therapy in Practice. If you dont have previous issues of the magazine, check out the abstracts on this website and take advantage of our new article ordering service. If you liked... Jan Stanier, try How I manage head and neck cancer (Autumn 1999): (084) Robinson, F. (Setting the Standard), (085) Machin, J. (A trouble shared) and (086) Salt, S. (Softening the Blow). Myra Kersner & Jannet Wright, see (126) Beeke, S. & Parker, A. (Autumn 2000) Competence, confidence and commitment. Della Money & Sue Thurman, look at (022) Hodgkinson, P. (Spring 1998) Communication in ALD - What do carers think? Lyn Steven, Janie Thompson & Denise Brown, see How I put practice into research (Spring 2000): (111) Law, J. (Good questions, good answers), (112) Valentine, C. (No assumptions) and (113) Langhorne, P., Legg, L., Pollock, A. & Sellars, C. (The burning questions). Sarah Howard & Cheryl Hughes, (145) Owen, R., de la Croix, H., Lewin, J., Lawer, E. & Davies, S. (Spring 2001) A first class team. How I train others in dysphagia, look at (135) Bowles, H. (Winter 2000) The need for Leadership.

Practical Communication: a programme for conversational practice & functional communication therapy

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Do you ever run short of things to talk about with clients? Speech and language therapist Sue Addlestone has produced this resource to help you develop functional language and promote carryover of therapy tasks into day-to-day conversation with a range of clients from 6 years old to adult. The Sourcebook of Practical Communication: a programme for conversational practice & functional communication therapy normally retails at 29.95 but Speech & Language Therapy in Practice has FIVE copies to give away FREE courtesy of Speechmark Publishing Ltd (formerly Winslow Publishing). To enter, simply send your name and address marked Speech & Language Therapy in Practice - Sourcebook offer to Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ. The closing date for receipt of entries is 25th October and the winners will be notified by 31st October. The Sourcebook of Practical Communication is available, along with a free catalogue, from Speechmark, tel. 01869 244644.

CONTENTS AUTUMN 2002


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AUTUMN 2002
(publication date 26th August) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Website design and maintenance: Nick Bowles Webcraft UK Ltd www.webcraft.co.uk Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2002 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site.

Inside cover Autumn 02 speechmag Reader offers


Win The Listening Skills Test and The Sourcebook of Practical Communication (and see p28 to win Feeding and Swallowing Disorders in Dementia).

14 Unlocking the voice


Tape recordings were made of connected speech immediately pre- and post-physiotherapy and showed a marked drop in habitual pitch and an extension of her pitch range at the bottom end following one session of manual physiotherapy. Just as previous studies have shown the value of osteopathy in voice work, Lyn Steven, Janie Thompson and Denise Brown believe a joint speech and language/ physiotherapy approach could be the key for a specific group of clients.

4 Inclusive communication coming soon near you?

...the Means, Reasons and Opportunities model has Della Money & Sue Thurman been adapted for use as a working model for a framework of inclu20 Reviews sive communication as part of Dysarthria, puppetry. our communication strategy From last to first resort across Nottinghamshire. Complete change of anything is a frightening Della Money and Sue 21 Getting concept to many of us. Our experience has shown Thurman describe how the comfortable us how, by not being afraid to start from scratch, Means, Reasons and we can dramatically improve apparently with Opportunities model of irresolvable problems. communication is evolving. collaboration Sarah Howard and Cheryl Hughes herald the ...confidence is introduction of a new paediatric care pathway often acknowledged 7 Further reading and explain why the old system in Grimsby and to be a critical factor Parkinsons disease, Cleethorpes has had its (fish and) chips. in determining the velopharyngeal dysfunction, ways in which differential diagnosis, neurodevelopment, students work while on clinical specific learning difficulties. placement...the more opportunities they have to practise skills and the more 8 A shift of emphasis encouragement and support they have ...a patient choosing to continue oral to carry out different roles, the more intake may need to be advised on how likely they are to gain confidence. best to minimise risk...There may be an Are we giving students the preparation, Myra Kersner argument to withdraw speech and opportunities and confidence they need and Jannet Wright language therapy care at this point, to work collaboratively? Myra Kersner however I would argue that this is one and Jannet Wright investigate. of the stages within the care process where the speech and language therapist can offer the most support. 24 How I train others in dysphagia Jan Stanier explores the needs of Once David understood why I was asking him to clients with dysphagia associated with modify aspects of his eating and drinking he not only Jan Stanier incurable head and neck cancer, and complied, but co-wrote his guidelines and prompted finds an urgent need for development me to add please chop my meat up and add more work by the profession. gravy to his Delta Talker! Tracy Broadley-Jackson, Rachel Samuels with J Darren Chadwick and Nicole Morrissey recognise 12 IN MY EXPERIENCE: Where do that the client and other team members are crucial to you want to go today? meaningful change in dysphagia. The survey revealed that, overall, therapists like the concept of using computers to augment therapy but that a lack of resources affects how exploitable Back cover My Top Resources therapy software is. With careful selection of exercises and flexible use of Shirley Cottons evaluation of the INTACT software several different packages, a set of relevant and for people with aphasia shows that consultation and appropriate therapy tasks can be put together. partnership with users - in this case speech and Why - and how - Sarah Woodward and Alex Davies language therapists - is vital in finding out where are integrating the use of computers into therapy you want to be and how best to get there. programmes for people with aphasia.

18 COVER STORY

IN FUTURE ISSUES
Cover picture by Paul Reid. See p.18.

APHASIA AAC EDUCATION AUTISM NARRATIVE SOCIOLOGY ETHICS


1

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

news

Autism in schools
Education and health professionals have received guidance from the government to help them identify children with autism and provide the best standards of support. The guidance has been put together by the Autism Working Group which included two speech and language therapy advisers, Julia Ritchie and Sally Jones. Examples of good practice can be found with the guidance at www.dfes.gov.uk/sen. Meanwhile, questions are being raised about the ability of secondary schools in Scotland to meet the expected increase in demand for services for children diagnosed with autism spectrum disorder. The National Autistic Society points out that formal prevalence figures in Scotland are 1 in 121 compared with 1 in 86 in England and Wales, and that there are more affected children in primary than secondary schools. In addition to concerns that children with autism currently at secondary level have been missed, the report suggests already overstretched secondary schools will face huge challenges when the diagnosed children currently in primary school move on. The society calls on the Scottish Executive and local authorities to recognise these issues and take action to ensure that all people with an autism spectrum disorder are given the support they need to reach their potential. Autism in Scotlands schools: crisis or challenge? From the National Autistic Society, see www.nas.org.uk. Bear in the Big Blue House helps cut the cake at the official opening of I CANs Pembrokeshire Early Years Centre, the first of its kind in Wales. Picture shows (from l-r): Lynette George - Chairman of Pembrokeshire and Derwen NHS Trust, Gill Edelman - Chief Executive I CAN, Councillor Rosemary Hayes - Chairman Pembrokeshire County Council, Bear, Surrey Hartshorn - I CAN Speech and Language Therapist and children from the Centre.

Three parents, one social worker and a fiver


The national disability organisation for people with cerebral palsy - founded by three parents and a social worker with five pounds - is marking its 50th anniversary with an innovative oral history project. Service-users and members of Scope give first person accounts of disabled peoples lives in a book by Chris Davies which also features archive photography, past advertisements and campaigns and key dates. The full interviews have been placed with the British Librarys National Sound Archive as part of its Oral History Collection. Contributor Anthony Hewson, who has a son with cerebral palsy, says of Scopes impact, I hope [my son] feels he has grown up with a positive view of disability. I suspect hes probably got better opportunities now than at any previous time. What Id like to feel now is that he becomes part of the push [for change] - not with me, but on his own. Changing Society: a personal history of Scope, is 8.80, tel. 020 7619 7341.

Early dementia support


The first website to focus exclusively on the early stages of dementia has started with a discussion forum on speech and language therapy led by Karen Bryan. The Dementia Advice and Support Service (DASS) UK Learning Network is designed to be accessible and personcentred, and has sections for people with dementia, friends and family, primary and secondary care practitioners, people interested in volunteering, employment matters, medicines, and finance and legal issues. The Mental Health Foundation which is backing the project believes the early stages of dementia are often neglected but are crucial as the person is still able to make decisions and choices about their future. www.mhilli.org/dass.

Healthcare professions debate


Two contrasting views add to the debate on the future of inter-professional education for those entering the healthcare professions. The Institute of Public Policy Research - whose Future Health Worker project is due to report at the end of the year - has put two different proposals on its website. One offers a radical re-think of current approaches to the education of health care professionals, and changes in the wider health environment so that professionals who have been trained in new and different ways are adequately supported. Training licensed workers in a new Foundation Degree, integrated health and social care workforce planning and a single patient held record are some of the ideas. An alternative view is that the identity of existing professional groups should be maintained and backed by government policy, and the practical and logistical problems with inter-professional education fully confronted. See www.ippr.org.uk.

The best start


Government initiatives continue to target improvements in services for young children with disabilities in England. A planned early support pilot programme will offer children with disabilities up to the age of two and their parents practical help such as early identification and support to help language development, a developed key worker role and better inter-agency working. In addition, practical guides to encourage multi-agency working and to help local education authorities provide effective support following very early identification of deafness have been published. Together from the Start - practical guidance for professionals working with disabled children (birth to 2) and their families is out for consultation from the Department for Education and Skills and the Department of Health, see www.dfes.gov.uk/consultations/active/index.cfm?CONID=177. Developing Early Intervention / Support Services for Deaf Children and their Families, see www.dfes.gov.uk/sen/documents/ACFD94.htm.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

news & comment

Looking good
A new Video Interpreting Service aims to provide a communication link for users of British Sign Language during short contacts with companies, councils and GPs. The RNID hopes to make better use of its interpreters through the videophone service which saves on travelling time and improves speed of service. Organisations wishing to be involved need a videophone and an ISDN line. Details: Helen Arber, RNID, tel/textphone. 020 7294 3720, e-mail vis@rnid.org.uk.

...comment...
Avril Nicoll% Editor && Kinnear Square Laurencekirk AB&" 'UL

Get involved
22 October 2002 International Stuttering Awareness Day Bring a pound to work or school for the British Stammering Association. Details: BSA, tel. 020 8983 1003, e-mail sb@stammering.org. 29 September - 5 October 2002 Stroke Awareness Week Join in with mass skipping, or take up the eight-week challenge - by the final week you will be comfortable doing at least 30 minutes of exercise on at least five days, thereby reducing your risk of stroke. Details: The Stroke Association, tel: 01604 623933, e-mail administration@stroke.org.uk.

Real$world understanding
You had to be there but, for Big Brother watchers, comprendez? will forever be associated with contestant Tim Culley. As speech and language therapists we have some insight into what enables people to understand and be understood. And, as readers of Speech & Language Therapy in Practice, we use reflection to broaden our understanding of the real world. Della Money & Sue Thurmans development of the Means, Reasons and Opportunities model (p4) reflects their efforts to express - in an easy-to-understand way - how society can become more inclusive. Because understanding in the real world is so poorly understood generally, the model is explicit about the combined effects of verbal, situational and functional comprehension. As dysphagia is still a relatively young field in our profession, we can perhaps track our developing understanding of it more easily than other areas. There is a noticeable shift in focus from the clinical environment of an acute ward to the real world out in the community. A need for professional control and power is giving way to a multidisciplinary approach grounded in ethics, with the client and family at the centre. Jan Stanier (p8) and the How I train others in dysphagia contributors (p24) all recognise we have to work with the key people - clients and their carers. If they truly understand what is going on they are more likely to make changes and, if we know their wishes, we can manage risk more appropriately. We are also understanding that our professional future depends on being able to show that what we do is effective. Lyn Steven and colleagues (p14) were on the receiving end of some real-world interference when looking for conclusive evidence of the value of physiotherapy with clients with dysphonia. Anecdotal evidence is, however, promising, and we look forward to future developments. Development of the profession depends hugely on the next generation - our current students. They may be getting up-to-date theory, but are we giving them the opportunity to explore it in practice? In terms of collaboration with teachers, are the real world and the world students aspire to poles apart? Myra Kersner & Jannet Wright (p21) argue that more hands-on experience of liaison is necessary if students are to gain the critical factor of confidence. Real-world understanding sometimes means recognising that it is time to stop tinkering and to start from scratch. Sarah Howard & Cheryl Hughes (p18) took the scary step of introducing completely new care pathways for their paediatric clients, but were rewarded with shorter waiting lists, higher attendance and greater satisfaction amongst staff and clients. Computers become obsolete much faster than more traditional therapy tools, as Shirley Cotton (p12) found when consulting users of INTACT. However, with progress in technology and affordable software (see Sarah Woodward & Alex Davies, back page), we can see that the groundbreaking Means, Reasons and Opportunities model is as relevant to newer methods of communication as it is to more familiar ones. Comprendez?

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Internet helps refugees


The internet is helping provide better health services to asylum seekers and refugees. The HARP WEB project - Health for Asylum seekers and Refugees Portal - has three phases. HARP 1 aims to offer practical help for health professionals and voluntary agencies working with asylum seekers and refugees through fast, free access to a wide range of up-to-date information, contacts and specialist services. HARP 2 is in the early stages of development through consultation with asylum seekers and refugees to offer them information on health conditions and services in the UK in a range of languages. COMMUNICATE will be a multi-lingual health resource for all non-Englishspeaking communities. A pilot programme proved the popularity of a user-friendly, multi-lingual, multi-agency online appointment card which is automatically translated from English into any one of 30 other languages. A GP who participated in the pilot said it had significantly reduced the failed appointment rate. www.harpweb.org.uk.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

strategy development

Inclusive communication coming soon near you?


Della Money Sue Thurman

The white paper Valuing People committed speech and language therapy services to the promotion of choice, inclusion, independence and civil rights. With communication at the heart of this, Della Money and Sue Thurman describe how the Means, Reasons and Opportunities model is evolving to make explicit the responsibility we all share.

Read this
if you offer training believe comprehension is inadequately understood are developing service policies

ver ten years ago, the Means, groups, and more specifically to incorporate the Reasons and Opportunities model of role of understanding (Sutton & Thurman, 1998; communication was developed and Thurman, 2001). used for teaching a group of staff working with people with learning Expanding on our Means, Reasons and disabilities in Leicestershire by the first author. Opportunities model, we identified five core roles Subsequently it was used in Nottinghamshire as for our service (Table 1) which, to maximise the an integral part of the Talkabout Teaching effectiveness of communication, may be for Package (Money & Thurman, 1994; 1996). The (i) the individual original model (figure 1) has since developed and (ii) those in their immediate environment expanded to be used by a variety of therapists, (Bradshaw, 1998) and/or teachers, nurses, lecturers and other profession(iii) their local communities (Bradshaw & als, across a variety of specialisms, and throughCarnaby, in press). out the UK. This has led down interesting and Valuing People, the first governdiverse paths, and we Table 1 Core roles ment white paper for people with ourselves have continued 1. Managing health needs, for learning disabilities in over thirty to develop the model to example, hearing impairment, men- years, requires that all organisareflect both current and tal health and secondary speech tions working with people with emerging influences on and language therapy referrals learning disabilities both develop practice. However, we 2. Making information accessible, communication policies and proare still asked about the including simplifying spoken and duce and disseminate information original version, and feel in accessible formats. As we write, it is time to share our written language, use of signs and the Royal College of Speech & own development of the symbols, information strategies Language Therapists is finalising Means, Reasons and 3. Shared means of communicaclinical guidelines to highlight Opportunities model. tion such as objects, symbols, good practice in the delivery of From initially being signs, speech speech and language therapy for developed purely as a 4. Promoting reasons for compeople with learning disabilities. teaching tool to repremunication like choices and deciThese state importantly that, in line sent visually the imporsions with the themes laid out in Valuing tance of the relationship 5. Creating opportunities for People, speech and language therbetween the how, why, communication, for example apy service delivery should be comwho, where and when through a range of people, places mitted to the promotion of choice, of communication, inclusion, independence and civil Means, Reasons and and activities. rights. This type of approach Opportunities has come requires speech and language therto form the basis of all apists to consider communication our service delivery. This needs in the context of a social model of disability, includes initial carer interviews, through to alongside the broader societal issues (van der Gaag, detailed video recordings used for research 1998). It is vital that the speech and language ther(Money, 1997), and observations for service evaluapist is not seen as the sole person accountable for ation (Thurman, 1998). It has been extended to communication, and that it is a shared responsibiliunderpin evaluating service delivery (Money, ty amongst all of those who live or work with peo1997b; Money, 2002). It has also been developed ple with learning disabilities. for use within a number of different service user

Core roles

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

strategy development

Means
(How we communicate) speech & writing
Non-verbal signs symbols gestures body language facial expression pointing objects & pictures behaviour Paralinguistic volume intonation rate tone fluency

Reasons
(Why we communicate)
attention greetings wants/needs request information give information ask questions protest/deny feelings choices preferences

Means
(How we communicate)

Reasons
(Why we communicate)

COMMUNITY ENVIRONMENT INDIVIDUAL


Means Reasons

Opportunities
(Where, when and with whom we communicate)

(How we communicate)

(Why we communicate)

Opportunities
(Where, when and with whom we communicate)

Opportunities
(Where, when and with whom we communicate)
partner time & place shared language shared communication system shared interests Figure 1 Means, Reasons and Opportunities: The original model

Real-world understanding
Verbal Situational Functional

Real-world understanding
Verbal Situational Functional

Figure 2 Means, Reasons and Opportunities: The developed model

Figure 3 Means, Reasons and Opportunities: The working model

Developing communication policies or strategies to address these issues is therefore essential if we are to deliver on the white paper. A communication strategy is a multi-agency plan to develop a consistent and coherent approach to meeting the communication needs of people with learning disabilities, within both their daily environments and wider contexts. This includes facilitating the use and understanding of a range of different means, reasons and opportunities for communication. A successful strategy has to involve the key elements of management support, training, and networks, and be underpinned by agreed and adequate resources. (Jones, 2001). Recently therefore, the Means, Reasons and Opportunities model has been adapted for use as a working model for a framework of inclusive communication as part of our communication strategy across Nottinghamshire. As already described, the relationship between the understanding and use of means, reasons and opportunities for communication was implicit in the original version. However, we have found that the link needs to be made explicit due to the growing culture of consent, user involvement, advocacy and person centred planning for people with learning disabilities. The increased significance of these issues has revealed frequent confusion in staffs own understanding. Jones (2000) describes an evaluation of the Somerset Total Communication approach which found that, despite considerable emphasis throughout training, staff still failed to recognise the importance of verbal comprehension.

It is the relationship between functional, verbal and situational understanding that determines the service users level of real-world understanding.

Real-world understanding
We therefore believed it was necessary to develop a model of Means, Reasons and Opportunities

that incorporated comprehension explicitly, and introduced the idea of real-world understanding (figure 2). Using real-world understanding, we distinguish the differences between verbal and situational understanding, and introduce the concept of functional understanding, describing the effect of these three elements on the service users understanding of means, reasons and opportunities, out in the real world. Through functional understanding we are attempting to explain the impact on a users situational and verbal understanding of their physical, emotional and sensory well being, self esteem, context, time of day and relationships. It is therefore the relationship between functional, verbal and situational understanding that determines the service users level of real-world understanding. However, as we prepared to launch the concept of a communication strategy across Nottinghamshire, we realised that introducing real-world understanding to our model of inclusive communication was still not sufficient. The model would additionally need to encompass some service delivery principles, building on the core roles and focused across three levels. For a successful communication strategy that promotes inclusive communication, the model needed to represent individual, environmental and community focuses to service delivery. We defined an individual focus as person centred, based on a clear communication need, and delivered through specialist clinical and therapeutic skills. It may also incorporate focused health promotion. An environmental focus is context centred. It encompasses all training and development initiatives, from ongoing teaching (for example, Talkabout, signs and symbols, and our local Enjoyable Eating course), tailored workshops (such as Challenging Communication (Thurman & Sutton, 2000), using symbol software), to targeted sessions aimed to meet identified individual or unit needs. It also includes the role of health facilitation, providing access and support/advice for other professionals.

Thirdly, we defined a community focus, which involves service development initiatives, such as policies and public involvement including wider training and advice to other services in the community.

Best practice
The use of Total Communication or Inclusive communication is increasingly recognised as best practice and effective use of speech and language therapy resources (Jones, 2000; Bradshaw, 2000). A commonly agreed definition of these terms remains elusive, although the Royal College of Speech & Language Therapists guidelines will propose they describe an approach that seeks to create a supportive and effective communication environment, using every available means of communication to understand and be understood. Speech and language therapists have typically delivered their services through training, consultancy and other inter-disciplinary work with health and social care professionals and carers, alongside their specific therapeutic approaches (Money, 1997b; Purcell et al, 1999; 2000). However there is still a need to develop a more extensive evidence base on which to base its practice through sharing of skills and experience, with a responsibility on all practitioners to network with their colleagues and contribute to the growing body of evidence. So far, what key elements have we got for a working model of inclusive communication? A decade on, we still feel that means, reasons and opportunities are at the core of communication. However, in addition we need to be explicit about real-world understanding, and also incorporate our foci for service delivery - the individual, environment and the community. We therefore propose the working model illustrated by figure 3. We would welcome any comments and feedback that could usefully lead us all towards a comprehensive model for promoting inclusive communication. Della Money and Sue Thurman are heads of speech and language therapy services for people with learning disabilities, Nottinghamshire Healthcare NHS Trust. "

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

strategy development

References
Bradshaw, J. (1998) Assessing and intervening in the communication environment. British Journal of Learning Disabilities 26, 62-66. Bradshaw, J. (2000) A total communication approach: towards meeting the communication needs of people with learning disabilities. Tizard Learning Disability review 5 (1) 27-30. Bradshaw, J. & Carnaby, S. (in press) Talking normalisation: The role of communication in integration. Department of Health (2001) Valuing people: A new strategy for learning disability for the 21st century. London: Department of Health. Jones, J. (2000) The total communication approach: towards meeting the communication needs of people with learning disabilities. Tizard Learning Disability review 5 (1) 20-26. Jones, J. (2001) The Communication gap - a paper exploring the fundamental nature of communication achieving the New Vision of the White Paper Valuing People, Policy Forum: Foundation for People with Learning Disabilities, August. Money, D. (1997a) A comparison of three approaches to delivering a speech and language therapy service to people with learning disabilities. Unpublished PhD Thesis, De Montfort University, Leicester. Money, D. (1997b) A comparison of three approaches to delivering a speech and language therapy service to people with learning disabilities. European Journal of Disorders of Communication 32; 449-466. Money, D. (2002) Speech and Language Therapy Management Models in Management of Communication Needs in People with Learning Disabilities. Whurr. Money, D. & Thurman, S. (1994) Talkabout Communication. Bulletin of the College of Speech and Language Therapists 504; 12-13. Money, D. & Thurman, S. (1996) An introduction to Talkabout, Nottingham Community Health Trust. Purcell, M., Morris, I. & McConkey, R. (1999) Staff perceptions of the communicative competence of adult persons with intellectual disabilities. British Journal of Developmental disabilities. Purcell, M., McConkey, R. & Morris, I. (2000) Staff communication with people with intellectual disabilities: the impact of a work based training programme. International Journal of language and Communication Disorders 35 (1) 147-158. Sutton, K. & Thurman, S. (1998) Challenging communication: People with learning disabilities who challenge services. International Journal of Language and Communication Disorders 33; 415-420. Thurman, S. (1997) Challenging behaviour through communication. British Journal of Learning Disabilities 25;111-116. Thurman, S. (2001) Challenging communication. Mental Health and Learning Disability Care Feb 4 (6) 203-206. Thurman, S. & Sutton, K. (2000) Challenging Communication: a resource pack for SLTs working with staff who work and care for individuals who challenge and are challenged by services. Nottinghamshire Healthcare. van der Gaag, A. (1998) Communication skills and adults with learning disabilities: eliminating professional myopia. British Journal of Learning Disabilities 26; 88 -93.

Reflections
Do I see the importance of networking and contributing to the professions evidence base? Do we have the necessary support, training and resources to deliver on government policy? Do we update protocols to reflect current and emerging influences on practice?

..resources...resources....resources...resources...
African-Caribbean leaflets
Leaflets on healthy eating, high blood pressure and reducing the risk of stroke have been produced specifically for African-Caribbeans who are estimated to be twice as likely to have a stroke as Europeans. Free from the Stroke Association, tel. 01604 623933.

Autism jobs
A new service intends to provide a comprehensive link between job seekers and recruiters who work with people with autism. Users can search for jobs by keyword, employer and region. www.autismjobs.org.

Whats that Scally doing?


Learn about verbs and their actions in a fun way with Scally, a friendly alien. Scally can act out more than 400 verbs and aims to get children thinking about verbs in different ways. A booklet offering 50 activity ideas has a section devoted to special educational needs. Scallys World of Verbs - Single user 39.25 + VAT. Special price for parents 19.99 inc.VAT. From Topologika, tel. 01326 377771, www.topologika.com.

Encephalitis: the facts


Factsheets on encephalitis which can be downloaded from the internet include speech and language difficulties in children, practical advice for social workers, health visitors and therapists, and practical advice for teachers. For adults, in addition to factsheets on different types of encephalitis, recovery and rehabilitation issues such as memory problems, returning to work and the role of the occupational therapist are covered. See www.esg.org.uk.

Get active
Action Lotto, a game designed particularly for children with speech and language difficulties, allows pupils to identify and match everyday actions based around the home, in kitchen, bedroom, lounge and garden scenes. For 1-4 players, aged 4+, 29.95 from LDA tel. 01223 357788.

Hearing aid development

Charity at Christmas
The Fragile X Society has three Christmas card designs. Happy Santa, Leaving Bethlehem and Smiling Santa are each in packs of 10 costing 3. Details: Marie Williams, tel. 0290 575515. Signalong has three exclusive designs of Christmas card in a pack of six costing 5.50. Details: Mike Kennard, tel. 01634 819915.

The makers of the Adapto hearing aid believe it addresses the three main reasons for poor user satisfaction as it prioritises speech over noise, reduces the side effects of occlusion and reflects individual processing ability and preferences. From Oticon ltd via hearing care professionals.

Coming from Signalong


Signalong is developing new resources on health matters (well woman and well man) and what shall I wear today? To be involved in this process, contact Sarah Bissett on 01634 832469.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

further reading

Bouldoukian, J., Wilkins, A.J. & Evans, B.J.W. (2002) Randomised controlled trial of the effect of coloured overlays on the rate of reading of people with specific learning difficulties. Ophthalmic Physiol Opt 22 (1) 55-60. A randomised controlled trial has demonstrated that, for selected children with reading difficulties, individually prescribed coloured filters reduce symptoms of asthenopia. In the present study, we investigate the effect of individually prescribed coloured overlays on the rate of reading. Subjects were 33 children and adults who: had consulted a specific learning difficulties clinic; had received treatment to normalise any conventional optometric and orthoptic anomalies; and subsequently reported symptomatic relief from coloured filters. These subjects carried out the Wilkins Rate of Reading Test (which assesses visual rather than linguistic factors) under two conditions: with their chosen coloured overlay and with a control filter. Steps were taken to ensure that a strong placebo effect was associated with the control overlay and, when asked which they preferred, subjects were not significantly more likely to prefer their coloured overlay than the control filter (p=0.11). Nonetheless, the rate of reading was significantly faster with the coloured overlay than with the control (p=0.0019). Further analyses support the conclusion that individually prescribed coloured filters can improve reading performance for reasons that cannot be solely attributed to conventional optometric factors or to placebo effects.

El Sharkawi, A., Ramig, L., Logemann, J.A., Pauloski, B.R., Rademaker, A.W., Smith, C.H., Pawlas, A., Baum, S. & Werner, C. (2002) Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): a pilot study. J Neurol Neurosurg Psychiatry 72 (1) 31-6. OBJECTIVE: To define the effects of Lee Silverman Voice Treatment (LSVT on swallowing and voice in eight patients with idiopathic Parkinsons disease. METHODS: Each patient received a modified barium swallow (MBS) in addition to voice recording before and after 1 month of LSVT. Swallowing motility disorders were defined and temporal measures of the swallow were completed from the MBS. Voice evaluation included measures of vocal intensity, fundamental frequency, and the patients perception of speech change. RESULTS: before LSVT, the most prevalent swallowing motility disorders were oral phase problems including reduced tongue control and strength. Reduced tongue base retraction resulting in residue in the vallecula was the most common disorder in the pharyngeal stage of the swallow. Oral transit time (OTT) and pharyngeal transit time (PTT) were prolonged. After LSVT, there was an overall 51% reduction in the number of swallowing motility disorders. Some temporal measures of swallowing were also significantly reduced as was the approximate amount of oral residue after 3 ml and 5 ml liquid swallows. Voice changes after LSVT included a significant increase in vocal intensity during sustained vowel phonation as well as during reading. CONCLUSIONS: LSVT seemingly improved neuromuscular control of the entire upper aerodigestive tract, improving oral tongue and tongue base function during the oral and pharyngeal phases of swallowing as well as improving vocal intensity.

VELOPHARYNGEAL DYSFUNCTION NEURODEVELOPMENT


Kane, A.A., Butman, J.A., Mullick, R., Skopec, M. & Choyke, P. (2002) A new method for the study of velopharyngeal function using gated magnetic resonance imaging. Plast Reconstr Surg 109 (2) 472-81. The purpose of this project was to assess the feasibility of imaging the velopharynx of adult volunteers during repetitive speech, using gated magnetic resonance imaging (MRI). Although a number of investigators have used conventional MRI in the study of the human vocal tract, the mismatch between the lengthy time necessary to acquire sufficiently detailed images and the rapidity of movement of the vocal tract during speech has forced investigators to acquire images either while the subject is at rest or during sustained utterances. The technique used here acquired a portion of each image during repetitive utterances, building the full image over multiple utterance cycles. The velopharyngeal portal was imaged on a 1.5-Tesla GE Signa LX 8.2 platform with gated fast spoiled gradient echo protocol. An external 1-Hertz trigger was fed to the cardiac gate. Subjects synchronized utterance of consonant-vowel syllables to a flashing light synchronized with the external trigger. Each acquisition of 30 phases per second at a single-slice location took 22 to 29 seconds. Four consonant-vowel syllables (/pa/, /ma/, /sa/, and /ka/) were evaluated. Subjects vocalized throughout the acquisition, beginning 5 to 6 seconds beforehand to establish a regular rhythm. Imaging of the velopharyngeal portal was performed for sagittal, velopharyngeal axial (aligned perpendicular to the knee of the velum), axial, and coronal planes. Volumes were obtained by sequential acquisition of six to 10 slices (each with 30 phases) in the axial or sagittal planes during repetition of the /pa/ syllable. Spatiotemporal volumes of the single-slice data were sectioned to provide timemotion images (analogous to M-mode echocardiograms). Threedimensional dynamic volume renderings of palate motion were displayed interactively (Vortex; CieMed, Singapore). A method suitable for the collection and visualization of four-dimensional information regarding monosyllabic speech using gated MRI was developed. These techniques were applied to a population of adult volunteer subjects with no history of speech problems and two patients with a history of cleft lip and palate. The techniques allowed good real-time visualization of velopharyngeal anatomy during its entire range of motion and was also able to image pathology-specific anatomic differences in the subjects with cleft lip and cleft palate. These methods may be applicable to a wide spectrum of problems in speech physiology research and for clinical decision-making regarding surgery for speech and outcomes analysis. Fleisher, B.E., Baum, D., Brudos, G., Burge, M., Carson, E., Constantinou, J., Duckworth, J., Gamberg, P., Klein, P., Luikart, H., Miller, J., Stach, B. & Bernstein, D. (2002) Infant heart transplantation at Stanford: growth and neurodevelopmental outcome. Pediatrics 109 (1) 1-7. OBJECTIVE: To evaluate the growth and neurodevelopmental outcome of 18 surviving Stanford patients who received heart transplantations before their second birthday. METHODS: We compared the growth and neurodevelopmental outcome of these 18 patients with a second group of age-matched comparison patients who underwent other heart surgery requiring cardiopulmonary bypass. RESULTS: Difficulties with growth and development were more common in the transplant group as were neurologic abnormalities. Speech and language delays as well as hearing problems were also more common in the transplant group. CONCLUSION: Multicenter prospective longitudinal neurodevelopmental outcome studies of infant heart transplant patients should be conducted to provide a more efficient basis for evaluating management protocols and assessment of long-term outcomes and of the need for early intervention services.

This regular feature aims to provide information about articles in other journals which may be of interest to readers# The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing# Every article in over thirty journals is abstracted for this database% supplemented by a monthly scan of Medline to pick out relevant articles from others# To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris% Downe% Baldersby% Thirsk% North Yorkshire YO* +PP% tel# "'*)( )+"!,&% fax "'*)( )+"(()# Annual rates are CDs (for Windows -(): Institution .-" Individual .*" Printed version: Institution .*! Individual .("# Cheques are payable to Biomedical Research Indexing.

DIFFERENTIAL DIAGNOSIS
Murray, L.L. (2002) Cognitive distinctions between depression and early Alzheimers disease in the elderly. Aphasiology 16 (4/5/6) 573-85. Background: Currently, there is a diagnostic dilemma in terms of discriminating the reversible cognitive problems associated with depression from the irreversible dementia associated with early or mild Alzheimers disease (AD) in the elderly. Previous research has focused on contrasting memory functions in depression versus AD, and methodological limitations undermine the results of the few empirical studies that have compared the linguistic and attentional abilities of these two patient populations. Aims: The objective of the current study was to determine whether depression is associated with any unique form of deficit in language or attention, and consequently whether more comprehensive assessment of these cognitive abilities may help to distinguish depression from early AD in elderly populations. Methods & Procedures: Age-matched groups of elderly adults with depression, early AD, or no psychiatric or neurological problems completed a comprehensive battery of basic and complex attention, language, and memory tests. Outcomes & Results: Results indicated that of the various cognitive abilities examined, the attention abilities of the depressed group, in particular their attention performance latencies, were most compromised compared to the control group. Tests of complex attention functions, working and episodic memory, and high-level language comprehension and production were most useful at distinguishing the depressed and early AD groups. Conclusions: These findings suggest that use of a small subset of high-level cognitive tests may allow accurate discrimination of elderly patients with depression from those in the early stages of AD.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

further reading further reading further reading further reading

SPECIFIC LEARNING DIFFICULTIES

PARKINSONS DISEASE

FURTHER READING

professional role

Is speech and language therapy relevant when a client requires end of life care? Jan Stanier explores the needs of clients with dysphagia associated with incurable head and neck cancer, and finds an urgent need for development work by the profession.
if you negotiate life and death in your work place importance on morality want to be involved in developing the profession

A shift of empha
H
ead and neck cancer can present in many forms and at many different stages within the recognised disease process. The number and type of cases varies greatly across local regions and the world and there is a strong link between incidence and lifestyle factors. With fewer than 5000 new cases a year in Britain (Tobias, 1997), evaluation of clinical management and outcome is inevitably difficult. The rehabilitative role of speech and language therapists in head and neck cancer is well established, but what of our role within the context of dysphagia management in end stage care? Talmi et al (1997) found that, Pain, airway problems and dysphagia were the common problems reported and Regnard (1990) cites dysphagia in up to 83 per cent of head and neck cancer patients. Neither author specifies degrees of dysphagia and presumably the data encompasses a range from minimal disturbance to an inability to maintain functional oral intake. Lovel (2000) says, In a series of 150 patients with incurable head and neck cancer 50 per cent had pain, 38 per cent dysphagia, 28 per cent obstruction of the airway, 14 per cent a fungating wound, 12 per cent nausea and vomiting and 10 per cent dry mouth...such patients often have no distant metastases and therefore die slowly with increasing disability from local invasion and progressively distressing symptoms. The aim at this stage is to minimise symptoms, maximise and maintain safety of the swallow and to monitor changing status to ensure that decisions remain appropriate (figure 1). This is different from the typical acute neurological rehabilitative model on which much of our training in dysphagia is based, and is perhaps more closely related to the care of those with progressive neurological disorders or frail elderly clients. As one of the members of the team with the opportunity to develop a trusting relationship and rapport with the patient and carer, a speech and language therapists contribution to patient discussions and team decision making can be key to the patients perception of care and quality of life. In recent years, the management of people with head and neck cancer has begun to include a wider range of professional and support staff

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From the very moment of diagnosis, of equal importance to clinical management is awareness of the role and perceptions of the patient and carer.

both in the acute and community settings. This results in part from the publication of the report by Calman & Hine (1995) which sought to enhance standards of care for patients through the development of specialised multidisciplinary teams for all common cancers. At its best, this approach will lead to the involvement of a number of central and local agencies. Most patients will receive advice from nursing staff, a nurse specialist, dietitian, speech and language therapist, dental surgeon, perhaps a physiotherapist and may also be advised by an occupational therapist during the acute phase of care. Increasingly, in addition to the community based counterparts of many of the above, the role of a range of other community based services is becoming more central on completion of the initial phase of treatment. This may include district nursing staff, social work staff and designated liaison staff according to the service available in a particular area. In the UK, many patients will have contact with Macmillan Nursing Staff as well as hospice staff, charitable support services and voluntary groups. Typically, the patient will pass on to a rehabilitation pathway where the advice of all members of the team remains essential but where the input of relevant nursing staff, support staff and specialist professionals as well as allied health professionals will be key to the patients perception of support and eventual outcome. Many patients will then progress on to a longer term monitoring programme with eventual discharge (for example, after five years free of symptoms). For others, where symptoms persist or recur, management will shift in emphasis from a curative aim to become longer term palliative or end of life care. The term palliative is often used to mean end of life care however, Diehl (1994) demonstrates a true understanding of the meaning of palliative versus end of life care: Palliative care is part of a continuum of care for cancer patients and can be implemented at any level of the health care system from home to hospital or diagnosis to death. The consultant leading the multidisciplinary team is usually the person who will identify this shift in emphasis in consultation with other professionals involved.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

professional role

hasis
Beneficial

Figure 1 Definition of palliative care (NCHSPCS, 1999)

In a study of the profiles of dying residents of a nursing home, Parker and De Bellis (1999) concluded that adequate time, skill mix, staff development and support and the provision of palliative care education for staff and GPs were needed. While it is well recognised that, whatever their stage/extent, patients with head and neck cancer will benefit from palliation integrated into a complete cancer care programme (Diehl, 1994) and a multidisciplinary model of care, this is unfortunately not always the case and, Too often, teamwork is restricted to technical transmission of information or conversations in corridors (Burucoa, 1993). A model of working generally regarded as beneficial both for the multidisciplinary team and the patient is integrated care pathways (Ellershaw et al, 1997). This promotes the identification of specific aspects of multidisciplinary input which are the minimum required as the patient progresses through the care process. Intervention is recorded and analysed to provide confirmation that the patient has received the appropriate input and to assess effectiveness. From the very moment of diagnosis, of equal importance to clinical management is awareness of the role and perceptions of the patient and carer. This includes not only assessment of quality of life issues, but consultation about management options, providing accurate and updated information and allowing for patient choice including the opportunity for a change of opinion. Where possible, the patient needs to be aware of treatment aims and limitations. In some cases, patients and carers may prefer not to discuss treatment choices; this may present a difficulty for the care team but the patient must be free to state their preferred method of dealing with the situation in which they find themselves.

Palliative Care, as the World Health Organisation has recognised, is the active, total care of patients whose disease no longer responds to curative treatment and for whom the goal must be the best quality of life for them and their families. Palliative medicine is now a distinct medical speciality in the United Kingdom, it focuses on controlling pain and other symptoms, easing suffering and enhancing the life that remains. It integrates the psychological and spiritual aspects of care, to enable patients to live out their lives with dignity, as well as offering support to families both during the patients illness and their bereavement. It offers a unique combination of care in hospices and at home.
but the manner in which it is related. Unfortunately, this remains an area of little available information and quality of life questionnaires designed specifically for use with head and neck cancer patients may be unsuitable. As they tend to be presented with cascading scores for each element, they risk compounding any negative feelings at this stage. For the patient, many issues aside from clinical care may influence their response to the end stage situation, including emotional aspects such as adjustment, feelings of guilt, fear and anger as well as the effect of altered body image, self esteem, a sense of control over events and level of confidence. The effect of nutritional and pharmacological management may also impinge on the patients response and Enck (1989) comments that, The clinical consequences of dysphagia are malnutrition and dehydration which often lead the care givers and the patient/family into conflict regarding management.

(Enck, 1989). Enck goes on to say, Conservation treatment with diet, attention to oral hygiene, pain control, anti-emetics, steroids and radiation therapy can relieve dysphagia in about 60 per cent of patients. In many cases the typical bedside evaluation of swallowing may indicate that the oral route for nutrition and hydration presents some risk. This may relate to potential airway compromise with regard to clearance, fatigue effects or risk of aspiration. Other significant related factors include the effects of oral intake on the duration of life. In some cases, the question of prolongation or shortening of expected life at this stage will be relevant.

Risk versus benefit


Factors such as quality of life and social issues related to eating/drinking also become more significant. Where a patient chooses to continue oral intake in the knowledge of these potential issues, this presents a problem for the therapist. The situation is far removed from our traditional role in that, with an acute neurological patient, the team decision may well be to avoid oral intake and opt for a non-oral route on a short or longer term basis whilst rehabilitation or swallowing therapy is conducted. In the case of end stage head and neck cancer care this approach would be unlikely to be considered in the patients interests as there are a number of other factors to consider, the main one being patient choice. The question of risk versus benefit is highly relevant. Often, a compromise situation is chosen, as alternative nutrition/hydration at this stage of care is a contentious issue and much of the available research is against providing non-oral intake on the basis of its potential effects on prolongation of a life which may be considered by the patient to be of poor quality (Fainsinger & Gramlich, 1997). As a result, a patient choosing to continue oral intake may need to be advised on how best to minimise risk. The emotional benefit of maintaining oral intake may be perceived by the patient to be greater than the potential risk it presents. This may put the speech and language therapist in a vulnerable position professionally if the therapist does not have an established, recognised and ongoing relationship within the multidisciplinary team. "

Involved at any stage


The speech and language therapist may be involved in the care of this group of patients at any stage in the process from initial diagnosis to receiving a referral for a patient requiring end of life care. As a result, the nature and aims of the role vary in the same manner as for all members of the multidisciplinary team, and an awareness of issues of clinical responsibility and accountability is essential. There may be particular issues around the subject of oral intake (including medication) versus the deemed safety of the swallowing process. It is important to identify not only the nature and extent of the dysphagia but also the specific nature and the presence of any related factors which may be contributory, such as poor oral hygiene, and poor neuromuscular coordination

Seeking hope
How the patient and carer perceive treatment and outcome will depend greatly upon opportunity for tactful, gentle discussion and communication. Diehl (1994) notes that, These patients mostly realise that there is no cure and perhaps not even prolongation of life - they seek hope. It is therefore not always a question of what is said,

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

professional role

Five steps to better practice in end of life care


legal duty of care and accountability, as well as a discussion of risk assessment. In the meantime, those working in this field should at least have clear and detailed job descriptions and ensure they have written consent for their involvement.

There may be an argument to withdraw speech and language therapy care at this point, however I would argue that this is one of the stages within the care process where the speech and language therapist can offer the most support. This may be in relation to instigating textural, postural or presentation modifications or to advising carers on how/what the patient is likely to tolerate most successfully and to counselling type support for the patient and carer (see case examples in figure 2). It may also extend to recommending pharmacy support with regard to medication in liaison with appropriate agencies. The important issue would seem to be that any therapist working with patients with head and neck cancer at this stage should ensure that all patient decisions are made within the context of the multidisciplinary team where it is recognised that the lead consultant has ultimate responsibility for ensuring that the patient and carers are able to make informed choices. It is clear that a patients consent alone is insufficient; therapists must gain informed consent. Although the majority of patients with head and neck cancer are usually deemed competent to make a decision about their care, this can be affected by factors such as medication, and is certainly something we must ensure. Communication with the patient and carer is essential - this should be tactfully and sensitively delivered at the appropriate rate with adequate opportunity for discussion/changed goals. Information should be tailored to individual needs and reinforced with written material where indicated. In addition, the speech and language therapist should ensure that any team/patient decisions are well documented both in the medical case notes and departmental records.

Justify decisions

Competent and confident


It is essential to know where the speech and language therapy role ends and a need for further more specialised support begins as well as how to access any additional support via the team. A therapist should be competent to recognise when therapy input is unlikely to be in the patients best interests and confident enough to voice this professional opinion to the patient and team. In end of life care, it should be remembered that maintenance of an established supportive relationship with the patient and carers - even at the point where no further clinical advice is indicated - can serve to maintain a feeling of continuing support for the patient and carer and should not be underestimated in terms of the perceived quality of care. There are no clinical guidelines available from our professional body on management of end of life care and none planned in the immediate future. In Communicating Quality 2 (RCSLT, 1996), a reference to head and neck surgical patients includes a statement that, Intervention including counselling may be appropriate in cases where the client is in the terminal stage of a disease. Further clarification would be helpful here and with regard to the speech and language therapists

The general principles of an ethical approach to patient care imply the need to justify decisions and actions in moral terms. They include the concepts of beneficence (do only good), non-maleficence (do no harm), respect for autonomy Within post basic and more advanced training (patient wishes) and justice (fairness to patient courses in dysphagia, there does not seem to be and carers and equal access to resources). This may consistent inclusion of information or advice for the be of some assistance in justifying decision making practising therapist on the management of palliawith a patient who chooses to continue oral intake tive or end stage patients of any aetiology. Often and needs information from the speech and lanthe topic is included as a brief addendum rather guage therapist to minimise risk. However, as it than a key area of input. As a result there is potencould also be said that advising on eating and tial for considerable variability in the provision of drinking strategies at this stage is acting against speech and language therapy care and in the the principle of beneficence, at all times documenextent of speech and language therapy involvetation, decision making and regular opportunity ment at all stages of a patients for review within the context of the a patient choosing to progress through the support sysmultidisciplinary team is essential. tem. Looking beyond our own profes- continue oral intake It is recognised (see for example sion for guidance, there are no RCSLT, 1996) that undergraduate Scottish Intercollegiate Guidelines may need to be Network (SIGN) guidelines in this advised on how best and postgraduate training for speech and language in the area of area and none planned. A clinical head and neck surgery care, particstandard (CSBS, 2000) does not to minimise risk. The ularly in end stage care, is sparse. include specific reference to head emotional benefit of This raises the question of whether and neck cancer but does outline maintaining oral the profession needs to highlight key palliative care aims including:this area of practice and examine controlling pain and other intake may be the required competencies within it. distressing symptoms. perceived by the Any speech and language thera helping patients and families patient to be greater pist undertaking to work with the cope with the emotional upset head and neck cancer client group and practical problems of the than the potential and, in particular, patients requirsituation. risk it presents. ing end of life care, should ensure helping people to live as actively that they are competent to do so. as possible despite their illness. At the moment, this means completion of a post supporting families and friends in their bereavement. graduate qualification in swallowing, mainteThe speech and language therapist should be nance of a personal log of development activities able to contribute to all of the above. and ideally advanced study in head and neck therA consensus document on effective head and apy. Many therapists benefit from working with neck cancer management (BAO-HNS, 1998) outlines an experienced colleague in a mentoring relathe nature and incidence of a range of head and tionship whilst establishing individual clinical neck cancers. It discusses methods of review and knowledge and confidence. quality assurance as well as areas of development As a profession, we could begin to address these and quality of life measures. It specifically disissues through a working group in conjunction cusses the rehabilitation of speech and swallowing with ongoing projects such as the competencies and highlights the need for the multidisciplinary and clinical guidelines projects (Royal College of team to include an experienced lead speech and Speech & Language Therapists, see language therapist. Unfortunately, whilst the secwww.rcslt.org). A more flexible approach may be tion on palliation includes discussion of the key to instigate specific interest groups with a focus elements of palliative care and emphasises the

1. Put clients and their families and their changing needs and wishes first. 2. Be sensitive to beginnings, shifts and endings and their implications. 3. Minimise symptoms and risk, maximise quality and monitor/review constantly. 4. Ensure multidisciplinary working, preferably through an integrated care pathway. 5. Recognise support at the end of life is valuable to perceived quality of care.

need for multidisciplinary working, it in common with Calman & Hine (1995) - does not specifically mention the role of the speech and language therapist. It does however stress the need to treat concurrent symptoms such as breathlessness and nausea. Presumably, dysphagia and eating difficulties could be included within this category, which would necessitate our inclusion.

Training

10

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

professional role

Figure 2 Case examples

on end of life care; this could incorporate degenerative neurological and frail elderly groups where similar issues arise. I hope that, in raising these questions, this work may contribute to the continuing development of the profession. Jan Stanier is head speech and language therapist at the Royal Alexandra Hospital in Paisley, tel. 0141 580 4019. This work was completed as part of the Advanced Dysphagia Course (Level 3) at Manchester Metropolitan University. Additional note: Since this work was written a further BAO - HNS document is planned which it is hoped will highlight some of these issues. The Clinical Standards Board for Scotland has also produced a further document on specialist palliative care.

References
British Association of Otolaryngologists Head and Neck Surgeons (1998) Effective head and neck cancer management - consensus document. London. Burucoa, B. (1993) The pitfalls of palliative care (Editorial) Journal of Palliative Care 9 (2) 29-32. Calman, K. & Hine, D. (1995) A policy framework for commissioning cancer services. Department of Health. Clinical Standards Board for Scotland (2000) Core principles of cancer care and standards for palliative care. Edinburgh. Diehl, V. (1994) Controversies in terminal care. Support Care Cancer 2: 82-87. Ellershaw, J., Foster, A., Murphy, D., Shea, T. & Overill, S. (1997) Developing an integrated care pathway for the dying patient. European Journal of Palliative Care 4 (6) 203-207. Enck, R. (1989) The management of malignant dysphagia. The American Journal of Hospice Care January/February. Fainsinger, R.L. & Gramlich, L.M. (1997) How often can we justify parenteral nutrition in terminally ill cancer patients? Journal of Palliative Care 13 (1) 48-51. Lovel, T. (2000) Palliative care and head and neck cancer. British Journal of Oral and Maxillofacial Surgeons 38: 253-254. National Council for Hospice and Specialist Palliative Care Services (1999) Directory of Hospice and Palliative Care Services. Parker, D. & De Bellis, A. (1999) A profile of dying residents in South Australian nursing homes. International Journal of Palliative Nursing 5 (4) 162-170. Regnard, C. (1990) Managing dysphagia in advanced cancer - a flow diagram. Palliative Medicine 4: 215-218. Royal College of Speech and Language Therapists (1996) Communicating Quality 2. London. Talmi, Y.P., Bercovici, M., Walker, A., Horowitz, Z., Adunski, A. & Kronenberg, J. (1997) Home and inpatient hospice care of terminal head and neck cancer patients. Journal of Palliative Care 13 (1) 9-14. Tobias, J.S. (1997) Management of head and neck cancer in Britain (Editorial) British Medical Journal 315: 1556.

1) A 90 year old man was admitted having presented with an advanced oral cancer affecting the left buccal mucosa, left retromolar area and pharynx. Chest status was poor and aspiration was suspected. Bedside swallowing assessment indicated a probable risk of aspiration on free fluids and large boluses of solids due to poor oral control, reduced base of tongue and pharyngeal wall action and clearance/fatigue issues. This gentleman was alert, aware and cooperative - he was afraid of choking but keen to eat/drink and desperate to return to the nursing home where he had lived for many years. Following team discussion and detailed speech and language therapist/consultant discussion, the decision was made to advise on modification of diet and presentation and to allow him to return home (with staff training). A recommendation was made for syrup textured fluids and soft/moist diet under the supervision of trained staff to ensure that presentation was by small bolus (5ml maximum) and placed to the right side of the mouth. A slight head turn to the left and chin tuck also aided clearance to some degree. Although it was clear that this regime would not entirely remove the risk of aspiration, it did allow this man to return home and continue to take an oral diet without fear. The quality of life for this man in his final weeks must surely have been greater than had he remained in hospital. 2) An eighty-two year old lady was admitted having been under the care of her ENT consultant for some time as an out-patient for a tumour of the right ear. Unfortunately, this had extended and was thought to be affecting cranial nerve function. A swallowing assessment was requested as she had been coughing on fluids and appeared distressed. This lady, whilst experiencing some cognitive impairment, was able to voice her choices clearly. As she had previously undergone radiotherapy, xerostomia (dry mouth) was a problem for her. She had chosen to avoid oral intake apart from fluids which had become extremely important to her to the extent that she liked to be able to see a water jug beside her bed. Bedside assessment indicated reduced oral control and probable airway entry pre/during the swallow. The swallow itself appeared inconsistent not always achieving complete laryngeal elevation. Cough reflex was strong but constant coughing was distressing for this lady. Therapy options were limited but we were able to advise her and nursing staff regarding optimal posture, bolus size, rate of intake and supra-glottic swallow. In addition, changes were made to her mouth-care regime. This appeared to enhance her well-being as well as allowing her family to see her looking more comfortable . Had we avoided intake of fluids, this lady and her family would undoubtedly have experienced a great deal of distress.
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11

in my experience

If a week is a long time in

politics, says Shirley Cotton, six years is a lifetime in

computer software, yet we are nothing like exploiting its INTACT package for people potential. Evaluation of the with aphasia shows that consultation and partnership with users - in this case speech and language therapists - is vital in finding out where you want to be and how best to get there.

Where do you want to go today? I


NTACT is a software package designed specifically for people with aphasia, developed in 1993 by our multidisciplinary Aphasia Computer Team. The software contains a library of over 500 exercises consisting of text, picture and sound based tasks to cover a range of activities from single word or picture matching to paragraph level tasks, and was used by Jane Mortley (1998) in her investigation of aphasia therapy. By the beginning of 2001, one hundred and fifty licensed copies of INTACT had been sold to speech and language therapists. As information officer, I had been involved in the development and marketing of the software and providing the support/training. During its early years INTACT was at the cutting edge of technology but if a week is a long time in politics, six years in computer software is a lifetime! In 1996 the operating systems DOS and Windows 3.1 were standard but during the following five years Windows 95, 98, 2000, ME and XP have superseded them. At the time of development INTACTs features were pushing technology to the very limit so the picture-based exercises were restricted to one picture on screen and sound samples were limited because the software was produced on 31/2 floppy discs.

The general observation was that good support is vital for software systems and one therapist reported that she would have given up long ago without it.

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if you need to make a case for more computers want more appropriate software for your clients are wondering whether to upgrade or start from scratch

Questions
Over recent months a number of questions were beginning to emerge in terms of the future of INTACT as a therapy tool, so we decided to investigate its current usefulness through a questionnaire to speech and language therapists who had purchased it. The questions covered a range of issues including the installation of INTACT, number of clients using it, usefulness in therapy, ease of use, technical problems experienced, exercise types, training and improvements. During July 2001 the questionnaire was sent to the 150 named speech and language therapists who had purchased the software.

Sixty-eight therapists (45.3 per cent) responded and they broadly fell into three groups: those who are using INTACT as a clinical tool - 63.4 per cent using it with between 1-10 clients - 26.5 per cent using it with between 11-15 clients therapists who have progressed as far as installation but have still to introduce it into their clinical work those who have tried to use it but technical problems have not allowed them to progress. The majority (75.4 per cent) reported that INTACT had been installed within a month of purchase, 12.3 per cent took more than a month and 4.6 per cent had not yet installed the software. A high percentage (68.8 per cent) reported using INTACT with their clients within a month after purchase. Take-up for the free INTACT training course was high as over half (50.8 per cent) had already attended and 42.9 per cent stated they wanted to. However, the survey revealed that due to staff turnover there are often no therapists remaining in the department who have attended the INTACT course and this influences whether the software is used or not. It also appears that INTACT needs to have a consistency of use within speech and language therapy departments so that new members of those departments are routinely exposed to it as a therapy tool. Of the respondents who had used INTACT (89.9 per cent), 74.2 per cent reported that they had found it useful in therapy, with 63.3 per cent using it with between 1-10 clients. The responses revealed it is being used with clients with high, moderate and low levels of language ability. Over 71 per cent reported that they found the Exercise Finder (where the therapist provides a set of criteria and asks the software to suggest exercise titles) to be useful in selecting appropriate exercises, while 31.3 per cent reported that clients found INTACT easy to use, and 40.6 per cent that clients found it neither easy nor difficult to use. Altogether about two thirds of respondents had experienced technical problems. Of these, about

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

in my experience

Figure 1 Respondents suggestions

half have now been resolved whereas for the other half the problem is still outstanding. This has had an impact on therapists overall impression on how easy INTACT is to use with only 40 per cent describing it as very easy to use or easy to use. The early installation method by 18 floppy discs was long-winded (this was replaced by CD-ROM installation in later editions), and there are reports of interference with other programs and vice versa and occasional unexplained shut downs of the program. More recent computers were incompatible with the INTACT disk operating system, while older PCs had insufficient memory for INTACT. Soundcard incompatibility caused the most difficulty with 39.7 per cent of therapists reporting this problem. When INTACT was written DOS (Disk Operating System) was the most recent operating system and, as Plug & Play hadnt been invented, INTACT had to directly manipulate the soundcard by using a procedure that is now obsolete. For the early users of INTACT this didnt pose any difficulty, as more often than not their computer didnt have a soundcard already fitted and the required one was easy to obtain. However, as time went on, computers were being purchased complete with soundcards and these were sometimes incompatible.

(a) New exercise types spoken word - picture matching more functional vocabulary more picture based low level exercises linked with voice recognition software to give clients a written representation of speech attempts linking in with theory of cognitive neuropsychology higher level activities - auditory comprehension - verbs and prepositions - construction of sentences in response to pictures/sentence processing tasks - syntax and grammatical structures/correct word order - non-word tasks - written and auditory - compound words - picture rhyming - written phrase choices - sequencing exercises - inferencing exercises - conversation based exercises - phonological exercises - sorting by initial sound, rhyme judgements - embedded clauses - responses to semantically/pragmatically rich pictures - functional therapy exercises (e.g. writing cheques) - low frequency word exercises

(b) technical capabilities/design alterations: windows format to allow easier installation use of high quality photographs and video to cover different parts of speech incorporation of still/video pictures of gestural systems ability to record and hear spoken attempts/use of patients voice for activating exercises more auditory and visual instructions and rewards easier authoring of exercises clearer categorisation of exercises according to purpose/what they aim to achieve phonemic/graphemic cueing (c) selection/user interface for both clients and therapists: picture icons for selection of exercises by client simpler way to locate exercises in an Exercise Finder as categorisation can be a problem in INTACT larger buttons, cursors and text clearer menu page instructions to be more aphasia and user friendly use of clients voice for activating exercises more interactivity - symbols/videos/audio
easy to use reliable easily upgraded supported. With these needs met and the incredible advances that have already taken place in computer technology, the skys the limit for the next generation of software for people with aphasia. Shirley Cotton is Information Officer for the Aphasia Computer Team at the Speech & Language Therapy Research Unit, Frenchay Hospital, Bristol.

Good support is vital


Therapists were asked to indicate how the Aphasia Computer Team help desk dealt with their technical problems. Overall it was reported that, with the exception of the soundcard difficulty, they resolved most technical problems. The general observation was that good support is vital for software systems and one therapist reported that she would have given up long ago without it. The therapists responses to the questionnaire showed they have clear ideas about what they need from software for therapy. Their suggestions (figure 1) fell into three areas:

a) new exercise types b) technical capabilities/design alterations c) selection/user interface for both clients and therapists. Although comments from therapists indicated that they found the INTACT concept a brilliant one, there are now too many barriers to its continued use in therapy. To remain a useful therapy tool INTACT would need to be extensively modified to take advantage of the new technology. It has been decided not to do this and so sales of INTACT have been suspended. We will of course continue to provide support for the software for as long as it is feasible. The Speech & Language Therapy Research Unit has collaborated in the production of the Step-by-Step software program used by Dr Jane Mortley in the Remote Based Therapy project. Step-by-Step will be available to speech and language therapists soon after September 2002 from Steps Consulting Ltd. The survey revealed that, overall, therapists like the concept of using computers to augment therapy but that a lack of resources affects how exploitable therapy software is. From the data gathered in the survey and from my experience of supporting and training therapists using INTACT it is clear therapists need/require: easy access to computers in clinic time to try out therapy software to explore the potential benefits time for training in understanding the basics of using computers and that they need therapy software that is:

Acknowledgement
I would like to thank the speech and language therapists who returned the completed questionnaires.

Reflections
Do I attempt to investigate further if I suspect something is no longer working? Do I take into account the time needed for familiarisation when buying resources? Do I give feedback to manufacturers about the usefulness of their products?

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research

Unlocking the voice


Does physiotherapy have a role in voice therapy? Previous studies have shown the value of osteopathy in this field but most clients do not have access on the NHS. While Lyn Steven, Janie Thompson and Denise Brown would have preferred more conclusive results from their research, they believe a joint speech and language / physiotherapy approach could be the key for a specific group of clients.

he idea for this project began after treating KM, a 70 year old woman with disordered voice. She presented with, among other vocal problems, an intractable high pitch which did not respond to conventional means of voice therapy. The presence of a psychogenic disorder was eliminated as a factor. Literature suggested that the problem may be due to locked cricothyroid visor (Harris & Leiberman, 1993; Harris et al, 1998) or other postural imbalances, and that this could be remediated by manual circumlaryngeal therapy. In the absence of such osteopathic expertise within the hospital, KM was referred for physiotherapy to mobilise her neck which had restricted range of movement. Tape recordings were made of connected speech immediately pre- and post-physiotherapy and showed a marked drop in habitual pitch and an extension of her pitch range at the bottom end following one session of manual physiotherapy. How might this effect be explained? Theoretically, poor neck posture can contribute to hypermobility of the upper cervical spine as a direct result of hypomobility or stiffness of the lower cervical spine and thoracic spine (Jull, 1986). The forward head posture which results leads to lengthening of the deep neck flexor group of muscles making them less effective as stabilisers of the cervical spine. This muscle imbalance could hypothetically lead to musculoskeletal problems which would have an effect on voice quality via the tensioning system of the cricothyroid mechanism. Habitual forward head posture can lead to the development of a cervico-dorsal shelf (figure 1). Success with KM and others raised the question: could this effect, similar in outcome to that reported by Harris et al (1998) using osteopathic and postural realignment techniques, be achieved by physiotherapy in other patients in conjunction with traditional voice therapy? As Schneider et al (1997) commented, Postural alignment is not an inherent trait....[but] is acquired through training postural muscle groups. We undertook a pilot study to find out.

Randomised control study


Based on the previous years referral numbers, we predicted we would receive between 60 and 70 new dysphonia referrals from ENT consultants annually. (Figures for 1998 were 14 male and 53 female patients). The original project design proposed that each new dysphonia referral over one year would be admitted to a randomised control study. It would exclude those over 75 years of age (who have normal, age-related changes in the larynx and voice), those with concomitant neurological conditions and those with contraindications to manual therapy (osteoporosis, previous cerebrovascular accident or malignancy, anticoagulant therapy, previous steroid therapy or longterm anti-epileptic therapy).

Read this
if you want to test out something which appears to work in practice work more closely with physiotherapists find out how research designs can be modified

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research

A control group would receive conventional voice therapy and a study group would receive additional manual therapy from the physiotherapist. Approval was sought and given from the Ayrshire & Arran Health Board Ethics Committee. Patients were informed and consented into the study with GPs notified of their patients involvement. ENT consultants gave blanket approval for each patient to be referred for physiotherapy at the speech and language therapists discretion. Patients were given a conventional initial interview by the speech and language therapist with a case history taken of relevant medical history and voice usage. A vocal assessment was carried out and the patient audiotaped reading the phonetically balanced Grandfather Passage and giving a sample of connected speech (Fex, 1992). The limitations of subjective analysis are acknowledged. However, there is sufficient support from the literature to indicate that while there still remained no gold standard for instrumental testing (Andrews, 1995), the human ear is the ultimate instrument in the evaluation of the human voice (Sonninen & Hurme, 1992). Each patient was rated on the revised Buffalo Voice Profile (III) (Wilson, 1987) by the speech and language therapist, and on a departmental vocal abuse record. The patient was asked to self-rate their perception of any neck problem and their voice problem using a baseline visual analogue scale and thereafter a weekly record. Each was also asked to keep a voice diary for one week to monitor voice usage and potential abuse. Each patient was seen for assessment by the physiotherapist to determine range of neck movement and suitability for manual therapy . Patients self-allocated randomly into either the study or control group by choosing a number from an envelope and were accordingly offered either a block of five speech and language therapy sessions plus five physiotherapy sessions or five speech and language therapy sessions only, chosen to reflect our average number of sessions. Patients were asked to rate their voice problem on a weekly basis using a visual analogue scale (figure 2). All assessments were repeated following the completion of treatment and the patient made a final rating of their voice and neck problem on a visual analogue scale (figure 3).

manual circumlaryngeal therapy (Roy et al, 1997). Despite discussion with ENT consultants in an attempt to stimulate a greater number of referrals, no significant increase was forthcoming. Thirteen of the 33 patients with dysphonia seen over the year by the speech and language therapist also had neck problems (39 per cent). Unfortunately only five patients could be included in the randomised control trial. Statistically we were advised by the Ayrshire & Arran Health Board Research Co-ordinator that this was an insufficient cohort of patients. We therefore decided to revise the project design to one of a single case study using a three condition ABC design:A = two weeks of repeat assessment with no treatment being given so the patient acts as their own control B = four weeks of conventional voice therapy C = four further weeks of conventional voice therapy plus additional physiotherapy. All other components of the previous design were maintained. An amended patient information leaflet was produced.

Lyn Steven

Janie Thomson

Denise Brown

Single Case Study


NS, a 69 year-old married man, was the only patient willing and deemed suitable for this phase of the study. NSs voice was hoarse, habitually high pitched with a reduced pitch range and intermittent periods of aphonia. He reported a daily fluctuation of voice quality although the overall severity of his problem had remained static over the three months since onset following an upper respiratory tract infection. On palpation, the cricothyroid visor was locked. Range of neck movement was reduced. Breathing at rest and for speech was clavicular. Conventional methods of assessing expiration control and phonation time were used; that is, sustained /s/ and /z/ with expiration control times of 23 and 11 seconds on repeated attempts at sustaining /s/. Phonation time was markedly reduced at 5 and 3 seconds on repeated attempts at sustaining /z/. A hard glottal attack was employed and considerable laryngeal constriction was utilised throughout phonation. No other patterns of vocal misuse were detected. He presented with mild asthma for which he used a Becotide inhaler, and slight hearing loss but without aid usage, and his hobby was presenting talks on local history to interested groups. He was a non-smoker although he spent most of his day in the same room as his wife who smoked heavily; he felt this to be a particular vocal irritant. Baseline self-rating on the visual analogue scale for severity of voice problem was 7 on scale of 010, where 10 was most severe. The therapists rating was 8 on the same scale. Traditional voice therapy procedures were carried out. General advice was given on good vocal hygiene, for example appropriate hydration levels, decreasing caffeine intake and reduction of"
Figure 1 Client with cervico-dorsal shelf

The parameters worked on in voice therapy most intensively were those showing the highest degree of positive change

Figure 2 Weekly Patient Visual Analogue Scale:WEEK 1: How is your voice at present?

0 1 2 no problem at all

9 10 extreme problem

How easily can you turn your head at present?

0 1 2 easily from side to side

9 10 not at all from side to side

Figure 3 Final Patient Visual Analogue Scale:WEEK 1: How much has your voice problem changed?

Psychogenic overlay
The predicted number of new patients was not achieved due to normal fluctuations and the loss of an ENT consultant, and by midway through the study period only 19 instead of the anticipated 30 referrals had been received. Numbers who met exclusion criteria, were higher than anticipated. Only seven met inclusion requirements and were willing to take part. Two of these withdrew due to family/personal problems. These personal difficulties had contributed a psychogenic overlay to the original dysphonia, although literature suggests that this patient group also benefit from

0 1 2 Got worse

9 10 Much improved

How much has your neck problem changed? 0 1 2 Got worse 3 4 5 6 7 8 9 10 Much improved

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

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research

Figure 4 Physiotherapy screening


Have you had: Neck Pain Upper limb pain Pins and needles Numbness Headaches Dizziness Have you ever had a neck x-ray? If yes reason: Y/N Y/N Y/N Y/N Y/N Y/N Y/N

shouting. Laryngeal constriction was addressed by means of standard relaxation exercises, retraction of false cords and use of Have you had any previous ingressive airstream. physiotherapy for a neck problem? Y/N Lower pitch, diaphragHave you ever had a whiplash injury? Y/N matic breathing and Observation of posture: increased breath conPast Medical History: Rheumatoid Arthritis Y/N trol were all encourMeasurements of flexion / Epilepsy Y/N aged and worked on. extension of the cervical Diabetes Y/N NS was encouraged to Other spine were taken using an monitor his own voice Drug History: inclinometer mounted on a Anticoagulants Y/N and voice usage by headband which was Steroids Y/N means of a weekly visual aligned to the tragus of the Other analogue scale and ear (Klaber-Moffett et al, Suitable for Study Y/N voice diary. These were 1989). Rotation in the ceralso completed on the vical spine was measured two occasions when the using a tape-measured disspeech and language therapist was on holiday. tance from nose to tip to anterior angle of The physiotherapist assessed NS using the stanacromion (Viitanen et al, 1998). dard neck assessment protocol (figure 4). This It was expected, with improved cervical spine was to identify any restriction in range of movealignment and posture, that the range of movement in the cervical and thoracic spine, and any ment would improve and/or become less painful. pain contributing to altered posture or movement Subsequently the patient would consider they had patterns. Movement pattern was noted in raising less of a problem with their neck which would be the head from a pillow, which identifies if a indicated by a lower visual analogue scale score. In patient recruits the superficial neck muscles in our single case study with NS, this was not the case. substitution to the deep layer.

Changes to voice use, quality and production techniques, and to neck status, were seen over the treatment periods.

"

Advice
Movement dysfunction was treated with manual therapy to mobilise stiff segments using Maitland mobilisations (Grade 3) to cervical levels C6 and C7 (Maitland, 2001). Advice on improving posture was given verbally, for example, sitting with the back supported to avoid slumped posture and an ideal head position when walking. To improve neck posture by shortening the lengthened deep neck flexors, NS was taught a strengthening exercise for this muscle group. Lying supine with the head supported on one pillow he was asked to put his tongue on the roof of his mouth and perform a retraction movement of the neck without using superficial muscles of the neck. Where the deep neck flexors are long and weak they become difficult to recruit and a patient will more readily substitute the superficial muscles, in this case the sternocleidomastoid. To ensure a specific contraction of the deep neck flexors, BioSense EMG electrodes were placed on the sternocleidomastoid and NS was asked to perform the exercise without the EMG increasing that is, with the sternocleidomastoid remaining relatively inactive during the exercise. NS was asked to hold the contraction for 10 seconds. It was noted if he was unable to do so and the time noted that he could hold the contraction without the superficial group being recruited. The exercise was repeated 10 times. NS was instructed to perform this exercise twice daily (10 seconds hold x 10). This has been shown to be an effective holding time to shorten postural muscle (Hides et al, 1996).

Positive change
The parameters worked on in voice therapy most intensively were those showing the highest degree of positive change, namely the use of diaphragmatic breathing for speech and a decrease in laryngeal tension (figures 5, 6 and 7). By the final assessment, diaphragmatic breathing was being used only for speech, not at rest. This could indicate the effect of awareness of a test situation whereby NS knows how to produce an appropriate breathing pattern but is not yet using this habitually. Further work would be required to promote carry-over to habitual usage. Reduction of laryngeal tension (initially rated 4) could be as a direct result of speech and language therapy intervention, physiotherapy, or a combination of both, given that there was no change in a tension rating of 2 following speech and language therapy only and following joint speech and language therapy / physiotherapy. Expiration time reduction at final assessment can be accounted for by an increase in NSs asthma levels on that day. Fluctuation of voice problems had decreased over time showing an increase in awareness and control of voice production techniques and improved vocal hygiene.

stamina was seen in the use of deep neck flexors. We felt the lack of range improvement was likely to be due to the patients osteoarthritic neck state. In the patients final visual analogue scale, after completion of therapy, he reported no change in his neck problem (lack of range of movement), but a marked improvement in overall voice status. The role of deep neck flexors was not recorded by NS but this does not mean the effect was absent. In all voice parameters targeted in voice therapy there were gains made to a greater or lesser extent as measured by the repeated departmental voice assessment. The Buffalo Rating Scale (III) was carried out by the research therapist and in a blind rating by a further speech and language therapist with considerable experience in the field of voice, to eliminate bias (Gelfer, 1988). Although there were some minor inter-rater discrepancies in the numerical values given, there was general agreement to the trend and areas of improvement. The patients own rating of voice showed minor fluctuations of voice quality from initial assessments, through the no-treatment phase and began to show substantial gains after weeks four and five of voice therapy (figure 8). Anecdotally, the researcher would expect improvement at this point in her treatment of most dysphonia patients. NS continued to rate his voice very good during the next period of the joint therapy approach. The shown results of this pilot study are discouraging, particularly when we had seen the effectiveness of manual physiotherapy for the cervical spine for several patients prior to the study being initiated, specifically in lowering habitually high pitch and extending pitch range. However, lack of sufficient numbers of referrals resulted in the abandonment of the proposed randomised control study. The single case study may have been seen to be more therapeutically valid on a patient who did not have osteoarthritis of the neck.

Opportunity
As many adult dysphonic patients are under sixty years of age they may experience poor posture but not necessarily have a reduced range of neck movement. This group may respond to physiotherapy based on postural exercises alone rather than solely manipulation. This would increase the patient cohort and therefore create an opportunity for further study into the role of physiotherapy in dysphonia treatment. A multicentred approach with larger numbers would be more statistically significant for a randomised controlled trial. The pilot could be extended, or repeated as a single case study with a different patient, should further opportunity arise. It is our considered opinion that patients with current emotional difficulties or history of psychiatric involvement, while probably benefiting from this treatment approach (Roy et al, 1997), would not make the ideal study subjects. Until this approach is demonstrated more scientifically, our impression remains that this is a valuable

Improvement
Changes to voice use, quality and production techniques, and to neck status, were seen over the treatment periods. It was agreed by both NS and the physiotherapist that no change had been effected in range of movement, although greater

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Figure 5 Scores using Adaptation of the Buffalo Voice Profile (III) (Speech and language therapy researcher rating)
Severity Rating 1 - 5 where 1 - normal and 5 = very severe

adjunct to conventional dysphonia therapy, especially where patients are using inappropriately high pitch and have difficulty in modifying this. Lyn Steven is a speech and language therapist at Crosshouse Hospital, Kilmarnock (tel. 01563 521133), Janie Thompson is a physiotherapist at Ayr Hospital (tel. 01292 610555) and Denise Brown is with the Clinical Effectiveness Department at Crosshouse Hospital (tel. 01563 577554). All work for NHS Ayrshire & Arran Acute Hospitals Trust.

Laryngeal Tone Hoarse

Pitch too high

Loudness

Nasal Res

Breath inadequate

Laryngeal Tension Hypertense

Rate

Voice Abuse

Speech Intelligibility

Overall rating

References
Andrews, M.L. (1995) Manual of Voice Treatment: Paediatrics through Geriatrics, Singular, California. Fex, S. (1992) Perceptual Evaluation. Journal of Voice 6 (2). Gelfer, M.P. (1988) Perceptual Attributes of Voice: Development and Use of Rating Scales. Journal of Voice 2 (4). Harris, T. & Lieberman, J. (1993) The cricothyroid mechanism, its relation to vocal fatigue and vocal dysfunction. Voice 2, 89-96. Whurr Publishers, London. Harris, T., Harris, S., Rubin, J.S. and Howard, D.M. (1998) The Voice Clinic Handbook. Whurr Publishers, London. Hides, J.A., Richardson, C.A. & Jull, G.A. (1996) Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine 21: 2763-2769. Jull, G.A. (1986) Clinical observations of upper cervical mobility. In: Grieve, G.P. (ed) Modern Manual Therapy of the Vertebral Column. Churchill Livingstone, Edinburgh, pp 315 - 321. Klaber-Moffett, J.A.K., Hughes, I. & Griffiths, P. (1989) Measurement of Cervical Spine Movements Using A Simple Inclinometer. Physiotherapy June, 75 (6). Maitland, G.D. (2001) Maitlands Vertebral Manipulation, 6th Edition. Butterworth Heinemann, Oxford. Roy, N., Bless, D.M., Heisey, D. & Ford, C.N. (1997) Manual Circumlaryngeal Therapy for Functional Dysphonia: An Evaluation of Short- and Longterm Outcomes. Journal of Voice 11 (3). Schneider, C.M., Dennehy, C.A. & Saxon, K.G. (1997) Exercise Physiology Principles Applied to Vocal Performance: The Improvement of Postural Alignment. Journal of Voice 11 (3). Sonninen, A. & Hurme, P. (1992) Terminology of Voice Research. Journal of Voice 6 (2). Viitanen, J.V., Kokko, M.L., Heikkila, S. & Kautiainen, H. (1998) Neck Mobility Assessment in an ankylosing spondylitis: A clinical Study of Nine Measurements including new tape methods for cervical rotation and lateral flexion. British Journal of Rheumatology 37: 377-381. Wilson, D.K. (1987) Voice Problems of Children. Williams & Wilkins, Baltimore.

1st visit initial assessments carried out 2nd visit in order for patient to act as his own control 3rd visit following completion of speech and language therapy treatment only 4th visit following completion of speech and language therapy treatment and physiotherapy

Figure 6 Scores using Adaptation of the Buffalo Voice Profile (III) (Blind rating)
Severity Rating 1 - 5 where 1 - normal and 5 = very severe

Laryngeal Tone Hoarse

Pitch too high

Loudness

Nasal Res

Breath inadequate

Laryngeal Tension Hypertense

Rate

Voice Abuse

Speech Intelligibility

Overall rating

Figure 7 Changes in assessment over time


Date of Assessment Breathing - Clavicular At rest For Speech Breathing - Diaphragmatic At rest For Speech Expiration Time (secs) Best of two attempts Phonation Time Best of two attempts Hard Attack Laryngeal Constriction 1-5 (1=least & 5=most) Fluctuation of Voice Problems Pitch range Habitual Pitch Caffeine Intake 1/9/00 Yes Yes No No 23 5 Yes 4 Yes 21/9/00 3/11/00 7/12/00 Yes Yes No No Yes Yes No No 19 13 Yes 2 Yes Yes No No Yes 8* 11 Yes 2 No

Reflections
Do I encourage clients to record and monitor their own progress? Do I make full use of second opinions (such as a blind rating) from colleagues? Do I consider the influence of a clients posture on their communication?

Reduced Reduced Reduced Reduced High High High High 6 cups Decaff Decaff Decaff coffee * increase in severity of asthma when assessment was carried out

Figure 8 NSs visual analogue scale scoring of voice


0 - 10 with 0 = no problem at all & 10 = extreme problem

Resources
BioSense Dual Channel EMG Feedback Machine: DMI Medical Ltd.
N.B. The Patients Neck Score stayed at 5 throughout the 12 weeks

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

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cover story

From last to first r


Read this
if you want to work more as a team use audit to demonstrate service improvements tackle seemingly insurmountable problems
Sarah Howard and some of the paediatric SLTs involved in changing the Care Pathway

S
referral stammer: initial assessment within 6 weeks (see figure 2)

Figure 1 Care pathway - community paediatrics

peech and language therapy departments nationally have suffered from continual recruitment and retention problems for a number of years. This is particularly so in areas such as Grimsby and Cleethorpes which are geographically further from big cities and universities. (Grimsby is renowned for its fish and chips and Cleethorpes is known as the last resort.) In 1999, our small but committed community paediatrics team reached a crisis point. Following initial assessment, children were having to wait up to 24 months for further input. Our annual forward planning day in September 1999 led to brainstorming and discussions for new models of service delivery to address these waiting times and, in January 2000, a new care pathway was produced and put into operation. Complete change of anything is a frightening concept to many of us. Our experience has shown us how, by not being afraid to start from scratch, we can dramatically improve apparently irresolvable problems. As a profession we have many excellent ideas, but need the opportunity and support to express then implement them.

Moved away
We moved away from a traditional to a three stage system (figure 1). The old system consisted of a centralised waiting list following an initial assessment. Groups were only offered as an option if therapist time became available. Now, after receipt of a referral, all children are seen within a 13 week period. They are routinely offered an initial assessment of one hour at a local clinic. Where children are found to have dysfluency, severe and complex needs, or further information is required, other assessments may be provided. Children with speech sound difficulties or language delay then follow the three stage system. Following initial assessment parents are invited to a parent information session (stage 1) where other carers or professionals involved are also welcome. Two sessions are on offer, one focusing on speech sounds and the other on language development. Each lasts approximately one hour and aims to provide information regarding normal development, general strategies and specific activities for home practice. Information sheets and workbooks are provided for parents to take home. In some cases it is appropriate for parents to attend both information groups so, following completion of one parent group, they sign up for the second. Parents are provided with a choice of dates and times (including some evening sessions), and are waiting no longer than two months. Numbers are usually kept to between 6 to 15 children represented at any one session. Parents are then asked to sign their child up for a recommended speech and language group (stage 2). Children cannot enter this stage until at least one parent / carer has attended a parent information session. An increasing range of groups is being offered, such as early communication, sound awareness, and speech sounds. These cater for four to eight children and are run by one therapist or a therapist with an assistant. Groups usually involve four to six sessions carried out on a weekly basis. Early communication groups consist of one home visit, video feedback and parent training, whereas phonology groups typically

initial assessment (within 13 weeks) severe/complex (see figure 3)


Stage 1 enabling parents

parents information session: phonology

parents information session: language

Stage 2 group input

phonology and sound awareness groups

early communication SULP groups/ (Rinaldi, 1995) Hanen (Manolson, 1992) review
Stage 3 individual input

one-to-one therapy discharge 18

severe/complex

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

cover story

resort
involve children and carers attending clinic together for all sessions. All children are offered a group within a target six month period. On completion the child is reviewed by their named therapist and is either invited to attend another group or to repeat the same group if appropriate, or placed on the waiting list for one-to-one therapy. This decision is made in consultation with the carers. Children who for exceptional reasons are unable to attend for group appointments bypass stage 2 and move directly to stage 3. Here, children who require one-to-one input following a review assessment receive one or more blocks of therapy and are expected to be working towards discharge.

Recruitment and retention difficulties led to crisis in Grimsby and Cleethorpes, with lengthy waiting times, poor attendance, unequal service and low staff morale. Sarah Howard and Cheryl Hughes herald the introduction of a new care pathway - and explain why the old system has had its (fish and) chips.
effect on learning potential. They will be offered further detailed assessment, one to two terms of clinic-based input with a specialist therapist, a school / nursery visit and programme, a home visit and referral on to other professionals. On completion of this package of care they may return to the community care pathway. Following a discussion between the severe and complex therapist and the community therapist, they will either enter at a relevant parent information session or be placed on a waiting list for one-to-one therapy. However, many children referred to the severe and complex caseload never return to the community system as they either receive a Statement of Special Educational Needs or enter the Child Development Centre.

Figure 2 Care pathway - dysfluency

referral initial assessment (within 6 weeks) primary aged and preschool stammerers older stammerers

Separate pathway
Children who are referred as dysfluent follow a separate pathway (figure 2). From receipt of referral they are offered an initial assessment within a six week period. This assessment may occur over more than one visit and usually contains a general screen of their global speech and language skills, a child interview, parental interview and a parent-child interaction video (Rustin et al, 1996). Following the initial assessment, preschool and primary aged children are prioritised as: no input required low / moderate risk: parent-child interaction therapy (Rustin et al, 1996) high risk: parent-child interaction therapy and/or direct work. They will then be reviewed, with homework tasks to ensure generalisation. Teenage stammerers are offered one to two packages of care, usually direct input, followed by a generalisation period of up to a year.

Comparison
The new care pathway came into operation gradually in 2000. An audit was carried out in 2001 focusing on two service standards, with a comparison made between standards achieved in 1998 and 2000. Standard One: A maximum waiting time for contact from the speech and language department of six months at any point in the care pathway. There was an increase in compliance of 11 per cent, with the 66 per cent waiting a maximum of six months for contact in 1998 increasing to 77 per cent in 2000. Standard Two: A 10 per cent decrease in the average number of Did Not Attends per child (excluding those who fail to attend their initial appointment) from 1998 compared to 2000. The actual decrease was 25 per cent, with the average number in 1998 being 1.21 compared with 0.90 in 2000. Further decreases are anticipated in the next year as the new care pathway is now fully in place and results were affected by the changeover period; for example, parent information groups were not running regularly until mid 2000, and increased sessions for running speech sound and early communication groups were not available until mid 2000. Parental expectations are now more comparable to the therapists, as this is addressed at the outset. We are seeing increased parental knowledge as shown by comments on what they felt they had learned following the parent information sessions: I know how to simplify language; I know how to help my "

parent-child interaction therapy (Rustin et al, 1996)

direct input

generalisation period (up to 12 months) discharge


Figure 3 Care pathway severe and complex caseload

An increasing range of groups is being offered, such as early communication, sound awareness, and speech sounds.

referral from community caseload (see text for critieria)

further assessment by severe and complex therapist (within 8 weeks)

Severe and complex


A child identified by a speech and language therapist as fulfilling the following criteria can be referred on to the severe and complex caseload (figure 3): involved with other agencies disordered or severely delayed speech and language skills high risk/high need children (Malcomess, 1999) no spontaneous progress

package of care (see text for details)

return to community caseload

Child Development Centre

statemented caseload

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

19

cover story

REVIEWS
DYSARTHRIA

Figure 4 Case examples

EMPHASIS ON RETAINING HUMOUR

My Stroke of Luck Kirk Douglas Little, Brown ISBN 0 316 85998 2 12.99
In 1995, Kirk Douglas had a stroke which resulted in dysarthria and this book recounts his initial struggle to come to terms with his disability, his gradual recovery, and his determination to continue improving. It is aimed mainly towards those who have had a stroke themselves and the opinion of one such person is that it conveys a very positive and encouraging message. The emphasis on retaining humour and the Operators Manual (a guide for recovering from a stroke) were especially liked. Short chapters and double-spacing make it a fairly easy read and the inclusion of pictures and anecdotes of famous people also enliven the book. This could not be classed as essential reading, but personal accounts of stroke are always interesting and, combined with anecdotes of famous people, this is no exception. Judith Sandeman is a speech and language therapist currently working as an Area Training Co-ordinator with Chest Heart & Stroke (Scotland)

PUPPETRY

James (b. October 1996) was referred in December 2000 by his teacher due to difficulties understanding him. He attended for assessment in February 2001 and was found to have a mild global speech and language delay. His parents then attended a parent information group (language) in March. By August James was offered a place on a Derbyshire Language Scheme (Masidlover, 1979) group. At his September review he had age appropriate speech and language and was discharged. Under the previous care pathway James would have waited between 18 to 24 months after his initial assessment for any further input. This shows the benefits to him of being provided with group input within a shorter period.

Callum (b. July 1997) was referred by his GP in July 2001. At assessment in August he had a moderate phonological delay. In October he attended four out of five group sessions to work on [f]. At review in January 2002 he still had some phonological immaturities, so was placed on the waiting list for oneto-one therapy which was offered almost immediately. Callum was discharged in February following one block of therapy as his speech sounds were age appropriate. The significant benefit of individual input within such a short period is only possible due to the large number of children discharged within stages 1-2 of the care pathway. Speedy passage through the pathway allows more time to be set aside for other children, keeping waiting times down.

Harvey (b. December 1998) was referred in February 2001 by his health visitor due to his lack of language. He was assessed in April and found to have a very restricted range of single word expressive language, but age appropriate verbal comprehension and social skills. His parents attended an information session on language development in May and were then offered a place on an early communication group in June. During this group Harvey began babbling and showed an increase in turn-taking skills. In August his progress was reviewed and, due to his continuing severe difficulties, he was transferred to the severe and complex therapist who diagnosed him verbally dyspraxic in October. Harvey has continued to receive specialist input. Harvey benefited from input at an early stage and on a regular basis. Parents were provided with information and general strategies. It was then possible for further assessment and input to be offered in a group environment which was more appropriate for a child of his age and difficulties than one-to-one. This led to more appropriate referral on and accurate diagnosis. One benefit to staff is the increased satisfaction in being able to offer a child with Harveys level of difficulties almost immediate input. Previously he may have waited for an extended period with increasing levels of frustration and anxiety for both Harvey and his parents.

A UNANIMOUS COOOOL!

I am the Story (the art of puppetry in education and therapy) Caroline Astell-Burt Souvenir Press ISBN 0285636197 12.99
Puppets help expressive, receptive and pragmatic language skills in a stimulating, exciting and fun way. This book is packed with information about the different types, how to make them, what to do with them and why. The author successfully combines theoretical and practical aspects with a wide range of clients. Triumphs and pitfalls are described through case studies. Throughout, the author emphasises the importance of evaluating the way the client uses the puppet, and a simple checklist is provided to assess this. The practical exercises are invaluable to the novice puppeteer. Instructions for glove, rod and shadow puppets and marionettes are accompanied by delightful line drawings, and attention is given to how and where to work them. Subsequent sections include puppets in narrative, as surrogates, and puppets to enhance language, communication and literacy. I thoroughly recommend this book which is readable, inspiring and would benefit clinicians of all ages and levels of experience. It makes you think, and inspires you to have a go. My first attempts, involving socks, buttons, beads and sponges, received a unanimous cooool! from pupils in Years 3-6 in a speech and language unit. Jill Spring works in speech and language bases in Dorset, and is a member of the diagnostic team for autistic spectrum disorders.

#child

make sounds. Attendance at groups following the parent information sessions has increased. This may be the result of parents being more involved in decisions regarding their childs therapy, and also a shorter waiting period before input being offered. Many children do not go on to require one-toone input, but are discharged at review prior to stage 3. This has had a knock on effect of reducing the numbers waiting for one-to-one. The waiting time at stage 3 is less than six months and attendance has increased. Staff morale has increased and the new system has allowed greater equity between community therapists service provision. Parent training and groups are available to all children irrespective of locality or individual caseload size, and input following initial assessment is always within two months (see case examples in figure 4). It is important that we continue to monitor and modify the changes we have made to reflect the shifting changes and needs of the population to which we provide a service. Sarah Howard is coordinator of paediatric services and Cheryl Hughes a speech and language therapist with Northern Lincolnshire and Goole Hospitals NHS Trust based at the Speech and Language Centre, 34 Dudley Street, Grimsby, NE Lincolnshire DN31 2AB, tel. 01472 313212.

TASLTM Conference, Edinburgh. Manolson, A. (1992) It Takes Two To Talk. Ontario: Hanen Centre Publications. Masidlover, M. & Knowles, W. (1979) Derbyshire Language Scheme. Derbyshire County Council. Rinaldi, W. (1995) Social Use of Language Programme for Primary and Infants. Guildford: Learn-Communicate. Rustin, L., Botterill, W., & Kelman, E. (1996) Assessment and Therapy for Young Dysfluent Children: Family Interaction. London: Whurr.

Acknowledgements
A special thanks to the paediatric speech and language therapy team based in Grimsby for their hard work and support in creating and implementing the new care pathway.

Reflections
Do we provide a service that is equitable and timely? Do we make sufficient use of groups? Do we have the opportunity to express and implement new ideas?

References
Malcomess, K. (1999) Delivering Clinical Governance in Speech and Language Therapy.

20

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

management

therapists and teachers are

learning to work together to meet the needs of

Getting comfortable with collaboration I


Speech and language children more effectively. But are we giving our students the preparation, opportunities and confidence they need to work collaboratively from the outset? Myra Kersner and Jannet Wright investigate.
n 1995 the Department of Human Communication Science at University College London introduced a professional studies strategic plan which led to innovative developments regarding clinical placements for the 260 students who are working towards becoming speech and language therapists (Kersner & Parker, 2001). Our clinical placements are offered in a variety of settings. Students work with different client groups, and this may be either on a day release or block basis. The department offers two pre-registration courses for speech and language therapy students: a four year BSc Speech Sciences and a two year MSc Speech and Language Sciences. The strategic plan is supported by a continuing series of workshops which are run for supervising clinicians. Now, students may be placed individually, in pairs or even as part of a team. For example, the initiative with therapists in the Hounslow area of London reported at the Royal College of Speech & Language Therapists conference in Liverpool (Parker & Kersner, 1998) has continued to be developed. Here up to 20 students at a time have worked in pairs as part of a team. It is not possible for all students to experience every type of client group or setting for themselves during their time at university. The integration of students theoretical learning in practical settings is therefore supported and facilitated not only by lectures, seminars and workshops but also by small group tutorials. Here the students have the opportunity to share and discuss their various clinical settings and their work with different client groups. From the first year of the courses, students are introduced to the concept of working with others including parents/carers/relatives, as well as colleagues in education, health and social services (Kersner & Wright, 1996; Wright & Kersner, 1999). In preparation for working in educational settings, theoretical approaches to the ways in which teachers and therapists may work together are introduced. These include a consideration of different models of collaborative working in schools as well as the barriers and facilitating factors such as those described by McCartney (1999) and Wright & Kersner (1998). Despite any difficulties which may arise, there is evidence to show that speech and language therapists and teachers are working closely together for children with communication problems in an attempt to provide more effective therapy (Law et al, 2000).

Opportunities
On graduating, a large proportion of students are employed as therapists within educational settings where they are automatically expected to work effectively with teachers. It therefore seemed important to establish whether their university preparation was appropriate and whether they had opportunities to observe the models of practice being described when they were on placement in educational settings. A study was conducted which was divided into two parts. The aim of the first part was to investigate whether our students were aware of joint working practices between their supervising therapists and teachers. If so, in what ways did the therapists work with the teachers and how did the students themselves work with the teachers while on placement? The aim of the second part was to investigate the perceptions of new entrants - on their 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/units. In the first study, self completion questionnaires were given to students in the third and fourth year of the Bachelors degree and both years of the Masters degree. They had already experienced working on clinical placement. The aim was to find out what joint working practices they had

Myra Kersner and Jannet Wright

Read this
if you want to be more innovative with pre$registration students help students work with other professionals change students perceptions of their role

From the first year of the courses, students are introduced to the concept of working with others including parents/carers/ relatives, as well as colleagues in education, health and social services

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

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management

Table 1 Activities undertaken by the supervising therapists with the teachers which had been observed by the students
Activity Responses

# either

(n=99) observed, or knew about through Give feedback to each re: work with children 44% discussion with their supervising therapists, Evaluate/record progress of specific children 33% while on paediatric placement. Work with teacher in classroom 30% A semi-structured interview was then Plan future work with teacher 26% conducted with 12 of the students about Contribute to Individual Education Plans 26% how they worked with teachers during Attend staff meetings 26% their placements. Observe each other working 25% Ninety nine questionnaires were analysed. Assess communication problems together 19% The students had been on a variety of Attend parents meeting 18% placements and some had been in more Plan modifications to the National Curriculum 16% than one educational setting. These included: Attend school INSET (in-service training) 15% mainstream schools (43) Run joint courses for other adults 4% special schools (32) Attend courses together 2% units in mainstream schools (27) nurseries (8) units in special schools (2) All students who responded indicated that they were aware of joint working practices occurring A second study was then carried out to investibetween their supervising therapists and the gate the perceptions of new entrants onto the teachers in the schools. Eighty seven percent of courses about therapists and students working the respondents indicated that their supervising with educational staff. Self completion questiontherapist talked to the teachers about the work naires were given to the next cohort of incoming undertaken with the children, although only 14 students on the first day of their courses. Both the per cent said that the time for such discussions MSc and BSc groups had had considerable prewas timetabled. course experience in educational settings, 90 per The students were asked to indicate the specifcent of the MSc students and 85 per cent of BSc ic activities that they had observed their supervistudents having worked or volunteered in such a sors carrying out with the teachers setting. However, these students (table 1). Some students indicated that, had not yet been on a clinical although they had not actually placement as a student speech and observed their supervisors engaged in language therapist. the activities, they knew through disAll the questionnaires were cussion that such activities occurred. returned so that 82 were available Students were asked how they themfor analysis. selves worked with the teachers while Almost all the students in both on placement. They indicated that they groups expected to share information received information from the teachers with their therapist about the chilabout curriculum topics and topic-relatdren they were working with. Almost ed vocabulary which they were then all also expected to be observed by able to use in their own work. For examtheir supervising therapist. ple one student said: The teacher is Although 87 per cent of the MSc really helpful. She gave me her targets students thought that they would for the Spring term and she was hoping share information with the teachwe could link up curricular aims. ers only 65 per cent of the BSc stuThe majority of students interviewed dents thought that they would do withdrew the children for their therathis. Less than 50 per cent of both py sessions and reported that they shared inforgroups thought that they would plan any future mation primarily with their supervising therapists work with the teachers. rather than the teachers, because they saw themThe students were also asked about what activselves as attached to the therapists. They did not ities they expected qualified therapists to carry see it as their role to provide written information out when working in a school setting The folabout the children for the teachers. lowing four were ranked highest by both student The students perceived liaison with teachers as groups: part of the therapists role, although not neces to assess communication problems with the sarily as part of their role as students. As they said, teacher The therapist did it best.; The therapist is very to give feedback to and receive feedback from competent, so it would not be appropriate for me the teacher about their work with the children in that situation. to evaluate and record progress of children However, the students did sometimes liaise with with the teacher assistants: The learning support assistant wants to plan future work with the teacher. to know what we did and wants to have teaching plans so that in the week she can go over them with that child individually... and next week shes In the first study it was encouraging to note that going to come and sit in on the session. 82 per cent of students had experienced a school-

Perceptions

Clinical supervisors and college-based tutors need to ensure that they help all students to maximise their skills from previous work experience and develop new professional skills

Encouraging

based placement during their course. The increasing number of mainstream placements now being offered for students also reflects the patterns of service provision in speech and language therapy which has changed in line with current inclusive education policy. An increasing number of children with communication problems are being educated in mainstream schools and speech and language therapists need to be able to work with educational staff from the moment of graduation. The importance of therapists working with educational staff has long been recognised (Lacey, 2001) and continues to be encouraged by government policy (DfES, 2001). While on placement in schools most students work with the same pupils on a regular basis, establishing and reinforcing their assessment and intervention skills. They do not work on a consultancy model and not all students become involved with working with other members of staff. Within the first study, those interviewed did not necessarily see liaison with the teacher as part of their role, although almost all of the questionnaire respondents indicated that they had observed their supervising therapists working together with teachers. It is possible that once they were involved in planning and carrying out therapy the students found it difficult to manage the additional task of liaising with the teachers. They possibly did not have the confidence to do this because, as some students said, they felt that, the therapist did it best. It is interesting to note that the students in the second study who had not yet been on clinical placement said that they saw liaison with educational staff as part of their student role. This was not how it was perceived by students in the first study who had been on clinical placement. Not unnaturally, 83 per cent of the students who were just beginning their course said that they expected qualified therapists to carry out the planning, therapy and liaison with others. Students in the first study reported that they discussed collaborative practices with their supervising therapist even where they had not directly observed such liaison. This indicates that they were aware of the importance of professional collaboration and that professional issues regarding models of practice are discussed on placement. As newly qualified therapists need to work collaboratively with teachers as soon as they graduate, such an awareness should go some way towards helping them develop ways of working in an inclusive education environment. When the new students were asked to indicate whether they would liaise with classroom assistants when on placement both groups said that they would, although this applied to a greater number of MSc (80 per cent) than BSc students (52 per cent). It is possible that all students might find liaison with assistants easier than working with teachers as many students nowadays have

22

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management

considerable pre-course experience as assistants. However, the variation between the MSc and BSc students may reflect the students life experience as 50 per cent of the MSc students were aged 25 years and over while only 19 per cent of the BSc students fell into this age bracket. These age differences may also account for other ways in which the students indicated that they might work. For example, more MSc students (67 per cent) than BSc students (46 per cent) indicated that they would give written information to the teachers about their work with the children when they were on placement. Such differences in age, life experience and work experience with related client groups mean that the students on these two courses may have different learning styles and will need to be approached differently to facilitate their professional development. Right from the start of the Masters course, students are expected to be ready for immediate client/colleague contact and involvement. The expectations for new entrant BScs, however, are different as these students have four years in which to develop their professional skills more gradually. Such differences and expectations are supported by the findings of this study.

modelling collaborative working practice providing opportunities for role play during workshop activities providing opportunities for contact to be made between students and teachers encouraging students to take more responsibility in relation to working with teachers, for example by gathering information about the children from the teachers, or by explaining therapy activities to them expecting students to take the initiative in liaising with teachers/assistants encouraging teacher colleagues to help foster working relationships with the students for example when they come into contact with them in the school staff room. Students need support and encouragement in order to adjust their perceptions and expectations about their role. In the same way, managers need to support and encourage newly qualified therapists so that they can have a clear and well defined professional identity... in school (Roux, 1996). Jannet A. Wright and Myra Kersner are senior lecturers at the Department of Human Communication Science, University College London.

Confidence
In discussion with supervising clinicians and students, confidence is often acknowledged to be a critical factor in determining the ways in which students work while on clinical placement. The more they are able to practise their professional skills the more likely students are to develop their confidence. Thus, the more opportunities they have to practise skills and the more encouragement and support they have to carry out different roles, the more likely they are to gain confidence. Clinical supervisors and college-based tutors need to ensure that they help all students to maximise their skills from previous work experience and develop new professional skills by:

References
DfES (2001) Revised Code of Practice for Special Educational Needs. London: The Stationery Office. Kersner, M. & Parker, A. (2001) A strategic approach to clinical placement learning. International Journal of Language and Communication Disorders 36 (Supplement) 150-155. Kersner, M. & Wright, J.A. (1996) Collaboration between teachers and speech and language therapists working with children with severe learning disabilities: implications for professional development. British Journal of Learning Disabilities 24 (1) 33-37. Lacey, P. (2001) Support Partnerships: Collaboration in Action. London: David Fulton Publishers.

Reflections
Do I work collaboratively and am I seen to work collaboratively? Do I acknowledge the critical role of confidence in student education? Do I give students the opportunity to observe and then to practise liaison?

Law, J., Lindsay, G., Peacey, N., Gascoigne, M., Soloff, N., Radford, J. & Band, S. (2000) Provision for Children with Speech and Language Difficulties in England and Wales: Facilitating communication between education and health. London: The Stationery Office. McCartney, E. (1999) Speech/Language Therapists and Teachers working Together: A systems based approach to collaboration. London: Whurr Publishers Ltd. Parker, A. & Kersner, M. (1998) New approaches to learning on clinical placement International Journal of Language and Communication Disorders 33 (Supplement) 255-260. Roux, J. (1996) Working collaboratively with teachers: supporting the newly qualified speech and language therapist in a mainstream school. Child Language Teaching and Therapy 12 (1) 48 - 59. Wright, J.A. & Kersner, M. (1998) Supporting children with communication problems : Sharing the workload. London: David Fulton Publishers. Wright, J.A. & Kersner, M. (1999) Teachers and speech and language therapists working with children with physical disabilities: implications for inclusive education. British Journal of Special Education 26 (4) 201-205.

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

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how I...

I train others in
Tracy Broadley-Jackson is a speech and language therapist with Stone Rehabilitation Service, Staffs, tel. 01785 271100. She would be interested to hear from others who have experienced changes in practices in nursing homes as a result of training. Rachel Samuels is a speech and language therapist and the dysphagia lead working with the Manchester Learning Disability Partnership. Darren Chadwick is a research fellow in speech and language therapy at the Manchester Metropolitan University working with the speech and language therapists in the Manchester Learning Disability Partnership. Nicole Morrissey is a speech and language therapist working in Medicine for the Elderly in St Jamess Hospital, Dublin.

dysphagia
Still relatively new to the speech and language therapists armoury% skills in dysphagia management are undergoing dramatic development# In particular% there is recognition that dysphagia has to be seen as part of a whole picture and that the client and other team members are crucial to meaningful change# So% how is this affecting the way that speech and language therapists offer dysphagia training to others? The experiences of our three contributors apply not just to training in dysphagia but every other area where we seek to share our expertise and broaden our skills#

Read this
if you want simple ways of training others to problem$solve to involve clients in their own management to be more aware of your skills in training others

1. recognise gaps between what you recommend and what is done 2. target the attitudes and knowledge of key staff 3. build on peoples knowledge of what they already do 4. show the whole picture not parts in isolation 5. draw on a variety of strategies (information, feedback, modelling and role-play) and forums (courses, case-focused) 6. demonstrate using props such as video 7. aim for people to identify and manage problems, or refer on appropriately 8. measure how training has impacted on practice.

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

Practical points for training

how I

mithard (1995) reports that a third of residents in nurscognitive and perceptual considerations and diet, nutritional ing homes have dysphagia. A study carried out by our and ethical issues taught by other members of the rehabilitainter-disciplinary community rehabilitation team tion team. (Shield & Hughes, 1998) corroborated these findings. Three questionnaires were administered before and after This prevalence of dysphagia does not match with the numthe course to the seven nurses attending from four homes. ber of referrals for swallowing assessments. Further, many of Questionnaire 1 asked the participants to explain what they these come from within the team itself when, for example, a understood by the terms dysphagia, swallowing, feeding, client referred having gone off their legs is found to have assessment and screening. The definitions given were coded underlying chest infections resulting from undetected swalas: correct, partly correct, incorrect, and different use of lowing problems. terminology. Overall, the scores were higher after the course Simply teaching nursing staff about eating and swallowing than before and the nurses had a greater depth and breadth difficulties in isolation - giving them one bite rather than the of understanding of terminology. whole apple - seems a limited exercise. In some instances, the Questionnaire 2 asked specific questions about clinical practice eating/swallowing problems are in themselves very minor. and knowledge, such as how many residents in their home had The difficulty lies in the whole picture of feeding, eating and feeding and swallowing difficulties, and would they routinely swallowing difficulties. Very often, correction of posture, proscreen for dysphagia. After the course, four participants stated vision of appropriate cutlery and verbal instruction are the they felt the number of residents in their homes affected was key factors in facilitating safe and efficient eating and swalhigher than they estimated before the course, and the others lowing. Steele et al (1997) and Backstrom et al (1987) showed indicated increased awareness. The nurses felt more confident that problems with posture, cutlery, cognitive status, staff in identifying and helping those residents, and able to pass attitude/knowledge, diet and level of supervision provided their new knowledge on to colleagues. were more prevalent than swalQuestionnaire 3 required lowing problems alone. them to view a video of a roleFigure 1 Alerters checklist Speech and language therapists play, and identify what was have realised the need to relinwrong and what they would ALERTERS TICK IF ACTION TAKEN PRESENT quish their stronghold in dysphado. No one person correctly PREDISPOSING gia. It is important to build on the identified all eight problems Neuromuscular knowledge and experience that either pre or post training. impairment, eg CVA nursing staff possess in feeding Most gave greater detail but, Reduced alertness clients - after all, they do it day-in, as a group, they collectively Reduced awareness day-out. A holistic approach is scored lower after the trainmore consistent with the philosoing. This may reflect some conPoor posture phy of an inter-disciplinary team, fusion and overload of inforDysarthria (weakness of and many problems that arise can mation, or that they were oral and facial musculature) be addressed, at least in the first remembering solutions rather Reduced mobility instance, with routine, practical than really problem-solving. It Increased/high levels of general actions such as ensuring the client might also be that the quesdependency with poor dentition is seated correctly. This is particutionnaire was not sensitive HEALTH larly true of clients in the commuenough to identify subtler Chest infection (recurrent, chronic) nity who often have chronic dyschanges in knowledge; certainDehydration phagia and for whom pneumonia ly some nurses overall scores Weight loss is more associated with the sequeremained the same although lae of long-term disability, such as they put in different informaMEAL TIME reduced mobility (Langmore et al, tion, suggesting they had Eating very slowly 1998). access to a wider range. Eating very quickly Training nursing staff is always In terms of how they would Food left on plate fraught with difficulties such as improve the clients difficulEasily distracted poor attendance and staff ties, all scored better on the turnover. These problems aside, post-course questionnaire. N-G/PEG in situ how do we know that what we These improvements reflected Reluctance to eat have taught them will be rememan increase in knowledge Avoiding foods bered and utilised? A lot of time across all areas of feeding and Food/drink on clothes and energy is put into preparing, swallowing difficulties, includdelivering and receiving any ing diet textures, perceptual SWALLOWING INDICATORS training, so we must feel confidifficulties and positioning. Drooling dent that it meets the clients In the last workshop the nursPooling needs and is cost-effective. es produced a checklist modiDifficulty chewing A two-day course was offered to fied from one of the overheads Coughing/choking before/ local nursing homes to for use in their homes (figure 1). during/after swallow 1) enable staff to identify feeding Twelve months later, staff from Weak cough and swallowing problems. two of the homes reported that 2) enable staff to initiate actions the checklist has influenced Wet or gurgly voice which might wholly or partly their overall screening for new remediate the problems. clients, whilst the other two 3) encourage staff to make timely and appropriate referrals course participants did not recall it. Although the checklist does for further assessment and intervention. not appear to have been incorporated into everyday practice, with As well as teaching about normal and abnormal eating and more support and training it does have considerable potential as a swallowing, the course also covered posture and positioning, screening tool, not only for nurses but other professionals too. This"

One bite or the whole apple?


By addressing the whole picture of dysphagia through training% health$ care professionals gain a wider range of skills to identify and manage the problem# Tracy Broadley$Jackson tested this out with nursing home staff $ and learned that such projects raise as many questions as they find answers#

PIC HAS BEEN REQUESTED BUT AS YET NOT RECEIVED

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

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how I

is particularly pertinent in an interdisciplinary community setting. I hope the training enabled staff to be in a better position to engage more fully in rehabilitation programmes instigated by the team - crucial to this is good communication aided by a common language. This point was highlighted in questionnaire 1, where a fourth category was included because the nurses placed a different emphasis on some words. For example, most nurses interpreted feeding as an activity which they did to residents (compared with my working definition taken from Logeman (1983), which is about the whole process of placing food/drink in the mouth, regardless of who does it). The study has raised a number of other questions: to what extent has the training impacted upon the nurses practice in the short and long term? are residents feeding and swallowing difficulties now being managed appropriately? how can we provide robust evaluation to demonstrate the benefits of training?

References
Backstrom, A., Norberg, A. & Norberg, B. (1987) Feeding difficulties in long-stay patients at nursing homes. Caregiver turnover and caregivers assessments of duration and difficulty of assisted feeding and amount of food received by the patient. Int. J. Nurs. Stud 24 (1) 69-76. Langmore, S.E., Terpenning, M.S., Schork, A., Chen, Y., Murray, J.T. & Loesche, W.J. (1998) Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 13(2) 69 - 81. Logeman, J. (1983) Evaluation and Treatment of Swallowing Disorders. Texas: Pro-ed. Shield, S. & Hughes, S. (1998) Dyphagia in Nursing Homes. Royal College of Speech & Language Therapists Bulletin (September). Smithard, D.G. (1995) Dysphagia should be investigated. Geriatric Medicine (January). Steele, C.M., Greenwood, C., Ens, I., Robertson, C. & SeidmanCarlson, R. (1997) Mealtime difficulties in a home for the aged: Not just Dysphagia. Dysphagia 12:43-50.

Read all about it! Fred the Head stops Mars Bars in bed
Do you realise how much training you do and the many different ways you offer it% often simultaneously? Rachel Samuels and Darren Chadwick take a systematic look at dysphagia training to benefit people with learning disabilities and find that% the more people are involved and understand what is required% the more they are likely to do it#

26

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

"

ur speech and language therapy team runs a twoday introductory course to eating drinking and swallowing problems for people supporting adults with learning disabilities and dysphagia. Complementing this is the extensive information given on an individual basis to caregivers and clients for each dysphagia referral. Training caregivers to manage a clients dysphagia varies from client to client and caregiver to caregiver, but there are commonalities. Dysphagia management involves moving from social support to social and medical support. Historically the social care philosophy has run the risk of leaving caregivers with no understanding of what has caused their clients learning disability, let alone their dysphagia, yet they are the key people advocating for the clients health needs. Part of training may well involve understanding for the first time the kind of neurological damage that may have led to a persons disability. This is important to dispel the myths of a person, coughing for attention, getting lazy with their eating or taking too long. In my practice dysphagia training always includes providing caregivers with sufficient anatomical knowledge to understand why something has gone wrong. For this, Fred the head, an anatomical model of a lateral cross-section of the head (with moving epiglottis), is invaluable. This helps equip caregivers with accurate terms and descriptions and establishes a common frame of reference from which to build up a picture of the difficulties the person they support may be experiencing. It should also help caregivers identify and describe clearly symptoms and exacerbating factors of dysphagia if they see them in other people that they work with. I use management strategies to guide training. Clients who have had a videofluoroscopy tend to have their tape held as part of their case notes and these are an invaluable training tool. The sight of aspirated tea mixed with a little barium heading down the wrong tube has been a powerful tool for change on many occasions. In addition, caregivers can clearly see why those extra few seconds before the next mouthful are so important when they observe a videofluoroscopy revealing pooling in the valleculae, or food or drink returning into the oral cavity as a result of poor cricopharyngeal opening. Shared experiences between the speech and language therapist, caregivers and clients of managing and living with dysphagia through the use of safe consistencies, positioning, utensils, support, pacing and prompting, help to not only share good practice, but also to enable a group to challenge practice that may be unsafe and inappropriate. This has been particularly apparent when talking about appropriate clothing

protection, meal presentation, and feelings about the use of specialised utensils that caregivers may feel are different. The other outcome is hopefully to ensure caregivers have the same mental checklist of management as appears in a persons written eating and drinking guidelines. I have found using a risk assessment framework has also worked well in equipping caregivers with useable, practical strategies. Training will aim to ensure that the risks of aspiration, asphyxiation, dehydration, poor nutritional status, injury, discomfort and a loss of personal dignity are highlighted. Formulating common sense risk reduction strategies helps to put the management strategies I may recommend in a meaningful form. Research conducted within our service (Chadwick et al., in press) has indicated that the knowledge caregivers have of the risks of non-adherence to dysphagia management strategies is a good predictor of actual observed compliance. I wonder if as a profession we are always aware of quite how much training we do? Most of our training is surely provided through the repeated visits we make to clients and their caregivers. Only when my co-author Darren pointed out to me that I didnt record how I had trained staff, did I begin to think about the different ways in which this is done. When writing up and classifying details of the dysphagia training we had conducted, using categories outlined by Jahr (1998), Darren noticed that we used many different types of training simultaneously. For example, a visit may well involve giving information, both written and verbal, about the nature of the problem, providing feedback on a caregiver or a clients technique of modifying consistencies or presenting food or drinks, modelling pacing, bolus size, and verbal or physical prompts. I had forgotten that I also use role-play to help caregivers understand why eating and drinking may be so fatiguing for the client. Maybe speech and language therapists would have a clearer idea about which aspect or combination of aspects of our support and training are most effective if we separated out the different types of training we use, or looked at them more systematically. Also it would be interesting to find out if different types of training were more effective with different caregivers or clients. Just when I think the training is complete I often revisit and fine tune aspects of a clients guidelines. This can be particularly useful in helping caregivers and the client to own the work that has been done. Consolidation of all of the above training strategies occurs in the formal dysphagia management guidelines written for each person with dysphagia. They include the nature of the problem, management strategies, potential risks and also charts for monitoring change (for example in Body Mass Index).

how I

"

Difficulties, despite the most thorough training, have been known. Training caregivers who are promptly moved two months later is common in all services. Challenging peoples firmly held beliefs and myths regarding food and drinks needs to be carried out with sensitivity, but does need to be achieved if the beliefs and myths are detrimental to a clients health. Julie, who is in her 70s, had refused a range of food options. When she was offered tripe almost as a joke, her reaction obviously indicated that she would like this. However, staff didnt feel this was a healthy or nice option. Hence, training was required to challenge staff preconceptions about food. This is a vivid example of a situation I often face, the need to work with staff and clients to establish the details of preferences and consistencies. Paid caregivers may well be trained and have a good understanding of safe practice. Families can be particularly resistant to speech and language therapy input around dysphagia management. In my experience this has ranged from not believing dysphagia exists to not believing that slowing the pace of the meal may reduce the risks of aspiration and asphyxiation. One method my team have used with some success in such cases is to ask paid caregivers to act as a model for the parent or family member.

The aspect that brings perhaps the greatest sense of satisfaction is the training I provide for the person with dysphagia. When we understand we are more likely to do. David only agreed to stop eating Mars bars in bed lying down when Fred The Head had demonstrated the risks. Once David understood why I was asking him to modify aspects of his eating and drinking he not only complied, but co-wrote his guidelines and prompted me to add please chop my meat up and add more gravy to his Delta Talker!

References
Chadwick, D.D., Jolliffe, J. & Goldbart, J. (2002) Carer Knowledge of Dysphagia Guidelines. International Journal of Language and Communication Disorders (In press). Jahr, E. (1998) Current issues in staff training. Research in Developmental Disabilities 19 (1) 75-87.

Resources
Fred The Head, an anatomical head with moving epiglottis and removable larynx is available from Adam Rouilly ltd, Castle Road, Eurolink Business Park, Sittingbourne, Kent ME10 3JG. Delta Talker is supplied in the UK by Prentke Romich International ltd, see www.prentromint.com.

n the course of dysphagia management, thickening fluids is a frequent recommendation made by the speech and language therapist. There is a wide base of evidence to suggest that changes in viscosity of fluid alter the biomechanics of the swallow (Smith et al, 1997). Reviews of the literature highlight changes with increased viscosity of a fluid: increased oropharyngeal transit times, intrabolus pressure, duration of pharyngeal peristalsis, duration of tongue base contact to the posterior pharyngeal wall and duration and excursion of hyoid movement. Upper esophageal sphincter parameters are also modified due to increased viscosity, and increased duration of relaxation (Smith et al, 1997) and opening (Kuhlemeier et al, 2001) have been reported. Therefore the patient who may be at risk of aspiration with free fluids may be able to tolerate fluids of a thicker consistency. However a significant difficulty with this line of management is patient compliance. 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. To address such issues I carried out a study to: 1. evaluate inter-rater reliability of various consistencies among speech and language therapists, nursing staff, ward attendants 2. compare and contrast general consensus within each group tested
Figure 1 Questionnaire to aid judgement Figure 2 Correct judgement

3. highlight the need for further training for specific groups 4. improve quality of thickened fluids being made by staff 5. improve patient compliance with thickener in fluids secondary to increased staff knowledge regarding thickened fluids. Five glasses of water (125mls each) were measured out. Each was thickened to a different consistency using a commercial thickening agent, Nutilis. Three of the consistencies were those as recommend by speech and language therapists: syrup consistency (two scoops), semi-solid consistency (two and a half scoops), set consistency (three scoops). Two distractors were used, a consistency too thin for a patient (one and a half scoops) and a consistency too thick for a patient (four scoops). Each consistency was made up by the same speech and language therapist, and each group of five left standing for approximately 10 minutes. Before being asked to identify the consistencies each participant Frustrated by the lack of was told that three of the consistencies were those recommended by speech and language therapists. They were also given written literature on the use of criteria for each (syrup, semi-solid, set). Each participant was also thickener in dysphagia% told that two of the consistencies were acting as distractors and Nicole Morrissey carried were to be described as generally too thin or too thick to be given to a patient. Each participant had then to fill in a short out a small study across questionnaire (figure 1) for each of the five consistencies and, based on the answers, decide on the category (figures 2, 3 and 4). " the Medicine for the

Consistent with consistencies

Occupation _________________

Occupation

Rating Scale
Please tick the appropriate box for each consistency Consistency A : Description Is fluid smooth ? Does fluid flow easily ? Can a figure of 8 be easily traced ? Will a plastic spoon stand up in consistency? Does fluid fall off slowly ? This is _____consistency Yes No
nurse ward attendant
Figure 3 Incorrect judgement

No. of participants

This consistency was correctly identified this percentage of the time: Syrup S/solid Set Too thin Too Thick 100% 80% 67% 100% 80% 67% 100% 100% 80% 50% 100% 100% 100% 80% 100%

speech and language therapist 5 5 6

Figure 4 Error analysis

Elderly Directorate# Her findings have led to a training programme for ward attendants to help them understand why their consistency with consistencies is so important#

This description of consistency syrup semi-solid set too thin too thick

...was wrongly applied this percentage of the time: 31.25% 25% 31.25% 0% 12.5%

This consistency ...was most frequently described as : syrup semi-solid set too thin too thick too thin syrup semi-solid or too thick n/a (no errors) set

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2002

27

how I

Of the three groups, the speech and language therapists were the most consistent in accurately identifying each consistency. This would be expected given that the department had drawn up the criteria defining each consistency. The group of ward attendants were the least accurate which is significant given that, at ward level, the majority of fluids are thickened by this group. This study highlights that discrepancies exist between what the speech and language therapist recommends and what the patient is getting. Inter-rater reliability is inadequate to ensure a patient is consistently receiving one of the three consistencies recommended on a daily basis by speech and language therapists. This in turn illustrates the need for inservice and further training that includes not only clear definitions of consistency but also rationales for the various consistencies used (Colodny, 2001) to reduce the risk of patients not receiving consistent treatment across the continuum from assessment to daily intake (Glassburn & Deem, 1998). Appearance of a food item is considered a major factor contributing to its acceptance (Ballou Stahlman et al, 2001) therefore if patients are receiving fluids that are over thickened, poor compliance should be expected. From the findings of this study a speech and language therapist is to offer a trial education period of all ward attendants starting in Med-El. After six months staff will be randomly assessed again. It is hoped that identification of consistencies as recommended by speech and language therapists will be improved. There are many limitations with this study. Small numbers of participants make it impossible to draw general conclusions. Some had more experience and education regarding use of thickener than others. One of the aims of this study was to increase patient compliance secondary to greater staff education. However as this was not objectively measured prior to assessment it cannot be measured objectively post-trial training period of

staff. It is also quite difficult to measure patient compliance with speech and language therapy recommendations. It can be subject to limitations such as recall bias and is dependent on the persons initial understanding of instructions (Low et al, 2001). This study highlights the point that recommendations need to be clearly explained to all other relevant members of staff involved with the patient. It cannot be taken for granted by speech and language therapists that what is being recommended is automatically what the patient is receiving.

References
Ballou Stahlman, L., Mertz Garcia, J., Chambers, E., Bosma Smit, A., Hoag, L. & Chambers, D.H. (2001) Perceptual Ratings for Pured and Molded Peaches for Individuals With and Without Impaired Swallow. Dysphagia 16: 254- 262. Colodny, N. (2001) Construction and Validation of the Mealtime and Dysphagia Questionnaire. An Instrument designed to Assess Nursing Staff Reasons for Non-Compliance with Speech and Language Pathologists Dysphagia and Feeding Recommendations. Dysphagia 16: 263-271. Glassburn, D.L. & Deem, J.F. (1998) Thickener Viscosity in Dysphagia Management: Variability among Speech and Language Pathologists. Dysphagia 13: 218- 222. Kuhlemeier, K.V., Palmer, J.B. & Rosenberg, D. (2001) Effects of Liquid Bolus Consistency and Delivery Method on Aspiration and Pharyngeal Retention in Dysphagia Patients Dysphagia 16: 119-122. Low, J., Wyles, C., Wilkinson, T. & Sainsbury, R. (2001) The Effect of Compliance on Clinical Outcomes for Patients with Dysphagia on Videofluoroscopy. Dysphagia 16: 123-137. Smith, C.H., Logemann, J.A., Burghardt, W.R., Carrell, T.D. & Zecker, S.G. (1997) Oral Sensory Discrimination of Fluid Viscosity. Dysphagia 12: 68-73.

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Are you looking for a text which combines research based information on feeding and swallowing in dementia with practical management strategies? Author Jacqueline Kindell - speech and language therapist and therapy services manager in Old Age Psychiatry - encourages a focus on the individual and a step-by-step approach of observation, documentation and management. Feeding and Swallowing Disorders in Dementia normally retails at 34.95 but Speechmark Publishing Ltd (formerly Winslow Publishing) is making FIVE copies available FREE to lucky readers of Speech & Language Therapy in Practice. To enter, simply send your name and address marked Speech & Language Therapy in Practice - FSDD offer to Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ. The closing date for receipt of entries is 25th October and the winners will be notified by 31st October. Feeding and Swallowing Disorders in Dementia is available, along with a free catalogue, from Speechmark, tel. 01869 244644.

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MY TOP RESOURCES
Why integrate the use of computers into therapy programmes? Setting up impairment based therapy programs on the PC not only provides more intensity of therapy but allows us in individual therapy sessions to concentrate more on other aspects of intervention, such as facilitating effective communication skills, and training carers and other conversation partners in strategies to assist people with communication difficulties Clients can take responsibility for some of their therapy by using the computer independently and choosing a time which is convenient for them Computers are increasingly being viewed as part of everyday life, therefore patients often feel they are getting back into an activity they did previously or, alternatively, learning a new, high tech skill which often increases their self-esteem and confidence

Sarah Woodward and Alex Davies are members of the Stroke Team across North Bristol NHS Trust# They have a patient accessible computer on two stroke rehabilitation wards% and computer equipment available for use in the community and in group settings# Recreational and leisure options are explored% as well as traditional speech and language therapy software#
During a course we ran in June% many delegates expressed an interest in forming a Computer Technology SIG to provide a useful forum for the exchange and brainstorming of ideas and equipment# If you would be interested% contact SarahWoodward (e$mail comptraining@lineone#net% tel# "''* -*" '!'! x !!+') or Alex Davies (e$mail alex#davies@north$bristol#swest#nhs#uk% tel# "''* -*( +,&+)#

Clients can discover new activities to replace some of the hobbies they now find difficult due to language or physical limitations Computer software resources enable us to adapt information to make it more accessible to people with language difficulties; we can quickly print out customised pictographic supported information in minutes for patient inclusion in meetings, issues of consent or communication charts/books. Getting started... 1. Following a stroke, many clients have to use their non-preferred hand to operate the computer. This can make using a mouse very difficult. Trackball devices, particularly those with the roller ball located in the middle, provide an easier means of mouse control. Given that the roller ball is central, they can be used by both left and right-handed users. We are using the Kensington Orbit which is usually available from Dixons or PC World for 19.99. 2. Some people find the characters on a standard keyboard difficult to see. Others find the array of different function keys somewhat scary - what if they press the wrong key? The QWERTY layout can take time to get familiar with and, for some people, the keys on the standard keyboard are just too small. Enlarged keyboards are simply plugged into the normal keyboard socket at the back of the PC. We particularly like the BigKeys keyboard range (100-130). They come with a choice of black and white or coloured keys, ABC or QWERTY layout, and there is also the option to purchase a keyguard (55). From Keytools Ltd, 023 8058 4314. Getting familiar with the PC 3. People who have never used a computer, or who are a bit rusty, need to familiarise themselves with the keyboard layout. They can do this in their own time, at their own pace, using the WAPS letter program (level 1). It presents each character of the keyboard on the screen in random order. The user must then find and type the letter on the keyboard. It keeps a running score of the time taken to find each letter, the number of errors and the location of the errors, useful for identifying visual field deficits or inattentions. FREE! from Northwick Park, tel. 4. Leisure tasks are often a good confidence-builder and show the person how they can use the computer to have fun. They can also be useful for building important skills such as opening a program or practising mouse control. In Jigsaw the person practises the click and drag functions of the mouse in a fun way. Given that it is possible to use scanned material or digital photos, the jigsaws are also easy to customise for each individual to make them as interesting and meaningful as possible. From Crick Software, 01604 671692, for 30 - a price most departments can afford. Moving onto speech and language exercises... 5. For those with dyspraxia who would like to work on their speech, a program is available which replaces the audio cassettes many therapists record for patients. Speech Sounds on Cue is an easy to use package which clients are quickly able to use independently. It provides multimedia cues for 531 CV and CVC words covering 19 consonant sounds in the initial position. One disadvantage is that the client does not have the opportunity to record their own speech attempts, although to some extent this could be overcome by setting up a tape recorder next to the PC. There are also 20 colour photos of consonant articulatory positions which can be printed out. Clients tend to find this package very motivating. From Propeller Multimedia, 0131 446 0820, 90. 6. A good set of tasks intended for people with severe to moderate aphasia is REACT. This is an easy to use language program providing interactive tasks with verbal instructions. Visual and auditory rewards are given for each task. There is also a record keeping facility to monitor improvements made over time. There are eight main sections: auditory processing, reading comprehension, semantics, sentence processing, spelling, time, money and visual matching. It is good as both therapy and assessment material. From Propeller Multimedia, 0131 446 0820, 425 (full version). 7. We have recently discovered ColorCards (Semerc, 0161 827 2927, 69) which we have installed on the ward computer. The program provides a series of activities based around picture cards presented on the computer for visual matching, semantic and categorization, and problem solving tasks. It is thus similar to the picture cards often used as resources in therapy but high tech, and therefore may feel more age appropriate for some people. Useful extras 8. For work on sentence building, and for clients with limited literacy who want to write cards/letters/emails, we find the Clicker program a handy adjunct to therapy. It can be used as a supportive writing tool. It enables the user to write with whole words without the need to generate phrases and is entirely customiseable to users vocabulary needs. It opens up within a simplified word processing window with a grid at the bottom of the screen. The grid is individually configured with as few or as many squares as is required. Each square on the grid contains a word/phrase which has been pre-stored and which takes only seconds to modify. The user can listen to the contents of each square before selecting it. The text chosen from the grid is then transferred into the word processing window to build phrases. From Crick Software, 01604 671692, 90. 9. For those clients with higher level language difficulties EFL packages can be very useful. They provide all sorts of tasks: naming, reading comprehension, spelling, following written/auditory instructions. With careful selection of exercises and flexible use of several different packages, a set of relevant and appropriate therapy tasks can be put together. The advantage of these packages is their price - they are mainstream software packages and therefore a lot cheaper than specialised speech and language therapy programs. Ones we have found useful include Smart Start English (from AVP, 01291 625439, 39.95) and Clarity Author Plus (from Wida, 020 8567 6941, 49.95). 10. For those clients who were previously crossword enthusiasts but who now find them too difficult, other puzzle programs can provide a useful alternative to fill the gap. Wordsearch (from GAMZ, 01684 562158, 49+VAT) is easily customised to enable you to change the grid size, font size and the word lists. It also allows you to make up your own wordsearch worksheet resources with your own vocabulary ideas.

Sarah Woodward

Alex Davies