Overheard: Giving Patients a Chance to Rehabilitate At a recent online conference, Jay Rosenbek — an expert on neurologic abnormalities of language, speech and swallowing—chatted with participants about a range of neurodegenerative disorders. The Leader listened in. Overheard
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Overheard  |   April 01, 2014
Overheard: Giving Patients a Chance to Rehabilitate
Author Notes
  • Jay Rosenbek, PhD, CCC-SLP, BC-NCD, is a professor in the Department of Speech, Language, and Hearing Sciences at the University of Florida, Gainesville. ■rosenbek@phhp.ufl.edu
    Jay Rosenbek, PhD, CCC-SLP, BC-NCD, is a professor in the Department of Speech, Language, and Hearing Sciences at the University of Florida, Gainesville. ■rosenbek@phhp.ufl.edu×
Article Information
Speech, Voice & Prosodic Disorders / Dysarthria / Swallowing, Dysphagia & Feeding Disorders / Overheard
Overheard   |   April 01, 2014
Overheard: Giving Patients a Chance to Rehabilitate
The ASHA Leader, April 2014, Vol. 19, online only. doi:10.1044/leader.OV.19042014.np
The ASHA Leader, April 2014, Vol. 19, online only. doi:10.1044/leader.OV.19042014.np
Joan Kosta: Another presenter commented that there is no evidence that strength training is effective with patients with neurodegenerative diseases. What is your experience with strength training, particularly with patients who have an oral dysphagia?
Jay Rosenbek: There is evidence that strength training—as in expiratory muscle strength training—can be helpful. It is not a cure-all. Strength training in dysphagia has been studied by Robbins and Steele—with interesting findings—and in amyotrophic lateral sclerosis by Plowman, with similarly intriguing results. Clearly, we have to avoid thinking that strengthening is the only approach, and usually to be maximally useful, strength training—when it is indicated—must be joined with skill training.
Lyndsey Fellows: This presentation was the first time I had heard the term “anarthria” [loss of articulate speech resulting from lesions of the central nervous system]. Can you give examples of what the treatment goals might be for someone with anarthria and what approaches might be used during treatment?
Rosenbek: Anarthria is usually not responsive to rehabilitation because the disease is far advanced. The usual approach is compensatory in both anarthria (no speech) and aphagia (no swallowing).
Joy Krueger: How do you go about distinguishing anarthria from a dysarthria or apraxia, especially when the patient has severe communication deficits?
Rosenbek: Anarthria is usually the last stages of either apraxia or dysarthria, or a combination of the two. In this condition, the diagnosis usually lies with the company the anarthria keeps. You look at language in other modalities and at the signs of profound weakness or other abnormality. You can even get help sometimes from the presence or absence of co-existing dysphagia. Sometimes the diagnosis is just your best guess.
Brook Swainson: Can primary progressive apraxia be the end disorder or does it always develop into something else? Have you seen it co-occur with progressive dysnomia?
Rosenbek: I have never seen a progressive apraxia of speech that did not end with significant language and usually cognitive deficit. Also, it can end with anarthria when combined with dysarthria. And yes, a naming deficit is often an early accompanying sign.
Adria Duncan-Campbell: In your opinion, which of the neurodegenerative disorders do you find most challenging to work with?
Rosenbek: Any of those that have an accompanying cognitive deficit. And those that may or may not have cognitive deficits, but which worsen and are also characterized by significant physical burden, such as progressive supranuclear palsy.
Duncan-Campbell: If your patients have had treatment with other speech-language pathologists before coming to your clinic, what do you see as being the biggest mistake made—that is, what can we as SLPs be doing better with these folks?
Rosenbek: My bias probably, but the biggest mistake I see is that someone has not been given a chance at rehabilitation. I know, as you do, that we cannot cure these folks but many have untapped emotional, physical and psychological resources that we can help them marshal.
Duncan-Campbell: With myasthenia gravis patients, I have had some neurologists state it is OK to work with them on swallowing exercises with rest breaks between exercises in session, but others say to wait until after their intravenous immunoglobulin course is complete, etc. As a general rule, how do you treat these folks with myasthenia gravis?
Rosenbek: We may suggest compensations before or during medical treatment but we wait for rehab until after medical treatments are complete. My experience has been typical of many of yours, I suspect—if they do not save their strength for functional activities, those activities do not go well. So we wait.
Lindsey Zurawski: You mention focusing on timing of the swallow versus only strength. Besides thickening liquids, what other strategies have you found helpful especially when a patient has impaired cognition—like some of our patients with Parkinson’s disease?
Rosenbek: I have to admit that we try to rehabilitate nearly all of our neurodegenerative patients at least for a few sessions, regardless of cognitive status. When those efforts fail we try to marshal family or someone to help with feeding to keep the person eating as normally as possible. I am not anti-compensations, but I go to them only after rehabilitation and every effort to get kind patient caregivers to help have failed.
Nina Lekchenko: With hundreds of neurological diagnoses out there, it is sometimes difficult to arrive to one disorder. Client’s performance may change from one session to the next. How long (how many sessions) it is OK to use in order to arrive to the diagnosis?
Rosenbek: I have to admit that I sometimes finish with a patient without ever knowing the diagnosis for sure. In those cases I am just cautious about prognosis, and am especially careful to have the patient identify subjectively if what I am doing seems to make things worse, better or to have no effect. Some of us work far from good health care and see patients with no diagnoses whatsoever. We of course don’t give them medical diagnoses, but we often have suspicions. And we organize our sessions for those folks carefully, so that if we are doing harm […] we can change procedures.
Janella Clarke: In the classification of the spinocerebellar ataxias, do the numbers related to spinal cord level suggest the course of illness or treatment needs?
Rosenbek: Yes, the level can be an influence. Higher in the spinal cord is the home of the respiratory muscle innervations. And, as you know, if the diaphragm and or other respiratory muscles are for speech, swallow can be affected, as can cough. I work with a neurologist who says that the nearly inevitable first sign of spinocerebellar ataxia generally is reduced cough. I have no idea if he is right, but it is important to know he feels that way, because we have good treatments for cough, including expiratory muscle strength training.
Maggie Rotter: As a therapist in a skilled-nursing facility, I’m seeing older and more baseline debilitated patients with neurodegenerative diseases who lack basic stamina to participate in an effective therapy or strengthening program. Along with this come home caregivers who have a hard time differentiating between “able” and “willing.” This puts a lot of pressure on both the patient and the therapist.
Rosenbek: I know what you are experiencing. The line between able and willing—if it is a line—is faint. I guess I never know for sure, but I have to believe after 44 years of practice that unable is more frequent than unwilling. What I think about such patients is that we try to give everyone who wants it a chance at rehabilitation, and try to tailor those rehabilitation efforts to the person’s strength. And we all have to admit—I think—that there comes a time for all of us when it is best to be left alone and provided with the very best in quality-of-life and comfort care a family, team or both working together can provide.
Allyson Stacy Watson: Do you have any suggestions for motivating Parkinson’s patients to participate in therapy, given the depression, apathy and decreased awareness of deficits associated with the disease?
Rosenbek: I can tell you work with these folks. I have no magic [solution]. In our center, we do what you do, probably: We try to establish contracts, and we are pretty straightforward in our discussion with patient and family that commitment is critical, and that we understand how hard commitment is when one has Parkinson’s disease. Sometimes the apathy, fatigue and other assaults on motivation are just too great. In those cases, we try to give the patient and family a short summary of what activities, preparation or posture will be associated with best performance, and tell them that when they have energy, using those tricks may help at least for a short time. I hate that we cannot make a difference for everyone, but alas we cannot—and part of being a good clinician is knowing when no more is possible. At least, that is the way it seems to me.
Mary Spremulli: Since the patients we are talking about have degenerative disorders operating in the background, won’t they all have a de-training effect back to baseline if they don’t continue to perform the skills training we have provided them? What do you think about singing and other related tasks—such as group classes—to help to maintain function of the respiratory and phonatory system in much the same way dance for Parkinson’s has become very popular for improving or maintaining motor function?
Rosenbek: Great observations. Yes, in degenerative disease, if one is to slow down the effects one has to continue some level of practice. And we are big believers in group activities for men and women with Parkinson’s disease. The American Medical Association says exercise is medicine and we agree. We encourage singing, walking, reading to the grandkids, going to hear music, dancing, playing cards and being as active as possible. Groups are critical.
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April 2014
Volume 19, Issue 4