Finding the Right Dose for Dysphagia Treatment

Unknown Speaker (0:15): Hi, Hi everyone. I'm Emily.

Unknown Speaker (0:17): And this is Eva.

Unknown Speaker (0:19): And you're listening to Speech Talk. We're your research book club, so you

Eva (0:23): can do evidence based practice in practice.

Emily (0:25): So let's start talking. Eva, tell me about your week.

Eva (0:29): I had a really great therapy week and it's not even that far. We're only on Wednesday. And I didn't work Monday. So yesterday was a good therapy day. I have a patient with Parkinson's who she has next to no voicing and is so spastic, so much muscle tenseness that she can't really move her mouth.

Eva (0:55): And so we were just practicing vocal Volleys that I learned about through Speak Out, which if you don't know their organization, they do a lot of speech therapy work for people with Parkinson's. It's basically their entire mission. And so we are doing the vocal Volleys like one, two, and you kind of sound like you're shouting over the person's head, and you can do mamay me moo moo. And her just silliness during the activity, like, just kept cracking up. You know, there are other people in the rehab gym and we're kind of yelling numbers at each other from three feet away, and it was goofy and it was fun.

Eva (1:34): And we've had some very emotional conversations about her change since she's had Parkinson's, and it just felt so good to laugh with her. And it just was one of those moments you're like, this is why I do this.

Emily (1:51): No. That's a that's a really good story. That's that's funny that something that you're referencing Speak Out because I just did that certification too.

Eva (2:01): Oh, really?

Emily (2:02): Yeah. And at work, I missed a phone call and it was someone calling me from Speak Out. It was one of their homeworks to be to call and make a phone call to talk to people using their intentional voice. So he's like, think because of your donation, I am able to make this call. Now granted, it is not a very big donation because I even though I'm graduated and working are still very poor.

Emily (2:28): So just because I said because of my donation, don't don't get it twisted. I'm it was not sizable. He was just calling to be nice. But it was nice to hear, you know, his his voice and that he was doing something and that he was making those phone calls and then people were encouraging him to do that. Like, that is a part of their program.

Unknown Speaker (2:49): So that's that's that's

Eva (2:52): That's really cool because, you know, we don't always feel connected to the CEUs or the certs that we do. It can just feel like, you know, I gotta block out six hours of my life to get this done so I can maintain my license. But it sounds like one, that was really impactful for you as a clinician and two, they connected you with the community that it benefits and that's really beautiful.

Emily (3:13): It was. We'll put in our show notes the Speak Out program. If you haven't done it and you work in this population, it's real it's a really good program. And they have a pay it forward model. So you donate what you can.

Emily (3:30): So even if it's not feasible for you to pay for expensive trainings, this is a good one for you to do and obviously it's a good program.

Eva (3:42): And if you're not a speech therapist and you just listen because you like to listen to random things, you could also just generally consider a donation. Anyways, Emily, what are we talking about this week?

Emily (3:55): So this week, I wanted to talk about dysphagia therapy dosing. I feel like a lot of times I have a dysphagia patient on my caseload and I'm like, okay. So we're gonna be working three times a week if it doesn't feel as if severe or five times a week if it's very recent. And then I'm just throwing exercises at them. I always we I am doing so many repetitions with my patients.

Emily (4:28): I drive them crazy. You thought your physical therapist was mean? Hello. My name is Emily. Get to work.

Eva (4:37): There's so many because I feel like one time we talked about dosing and you were like, I think I'm way overdosing dysphasia exercises. So one, I think it's full circle that we're really finding we're coming back to the idea of like, is the right dosage? And two, I am so excited because I think this is something that I definitely am limited in my knowledge of. My patients are always like, and how long do I have to do this for? And I'm kinda like, forever till it feels good.

Unknown Speaker (5:04): You tell me when it's right. You know what? You be the therapist.

Unknown Speaker (5:10): I know. And they're always so like, how many repetitions? And I'm like, I don't know. My favorite number is five. So we're just gonna do sets of five over five days.

Eva (5:19): Everything is five sets of five. Well, I think I don't actually know whether or not Instagram is an accurate place to get the pulse of the SLP world, but I did recently see a post by somebody who was I don't know if they're advertising or just trying to get the word about out about doing more minimal dysphasia exercises. They're like, I used to hand out a lot of exercise with several repetitions and nobody was doing it. So now I only do two and it has better sustainability. So who knows?

Eva (5:51): Maybe that's secretly the answer to everything.

Emily (5:54): Eva, do you feel like we were ever actually taught how to dose dysphasia therapy? Though we Short answer, were in grad no. Yeah, I agree. When we're in grad school, we're taught the general basis on why we do therapy, but not how to do therapy or what treatment will actually look like. So again, this is something I wanted to look into because like you said, I I know the muscles well enough.

Emily (6:26): Like, if you were to quiz me, I'd probably fail at this point, but but I know enough. I remember the why, but not the how or for how long. And I definitely didn't think about intensity very much. Like, I clinically think about intensity if somebody has an old stroke or their dysphasia is more of a presbyphasia just from old age or generally weakening. It's a lot different for for me when I'm planning a treatment intensity when I think about a new stroke.

Eva (7:04): Yeah. Or cognitive tolerance. We talk about that a lot that if you can only get someone to pay attention for thirty seconds at a time, there's only so many repetitions you can do.

Unknown Speaker (7:13): Right. Or maybe you can do more because that's all that they can remember.

Unknown Speaker (7:18): Terms what doing. We're doing more.

Unknown Speaker (7:20): Alright, guys.

Eva (7:21): Welcome to this therapy session again.

Emily (7:24): While you chew on that teaser, let's take a break, we'll be back in just a second.

Speaker 2 (7:31): Flowing ad budget on metrics that look great till the CFO sees them? That's bull spend. And marketers are calling it out in Dashboard Confessions.

Unknown Speaker (7:41): I remember telling my boss, it'll be good for the brand, when leads were slow. Yeah. It it wasn't.

Speaker 2 (7:49): Cut the bull spend. LinkedIn lets you target by company, job title, and more. Advertise on LinkedIn. Spend $250 on your first campaign and get a

Eva (7:57): $250 credit.

Speaker 2 (7:58): Go to linkedin.com/campaign. Terms and conditions apply.

Speaker 4 (8:02): This summer, Prime Video takes you back before Legally Blonde, before law school, and into the world of Elle Woods in high school. Set in 1995, this Gemini vegetarian knows exactly who she is until her family moves from Bel Air to Seattle. Packed with iconic fashion, 90s nostalgia, and a throwback soundtrack, Elle proves one thing. Law school was hard. High school was harder.

Speaker 4 (8:25): From the world of Legally Blonde, watch Elle, a new original series only on Prime Video July 1.

Emily (8:32): Alright, guys. Welcome back. So today's article we're looking at is titled Exercise Prescription for Dysphagia Intensity and Duration Manipulation by Christine Sapienza, Karen Wheeler Heglind, Kim Stewart, and Joseph Nosera. Yeah. So this article challenges a major assumption in dysphagia therapy that simply doing exercises is enough.

Emily (8:58): Instead,

Eva (8:59): they argue that how much, how hard, and how often we prescribe exercises matters just as much as the exercise itself.

Emily (9:06): Yeah. So before we really dive into the research, we have to get oriented a little bit. So they qualified treatment intensity. So we're talking about the magnitude or the force utilized in the exercise. So we're thinking heavy weights means more force you're applying to curl that weight.

Emily (9:28): So that same idea, how much force are we applying from our chin onto our sea turtles? How hard are we pushing our tongues on those depressors?

Eva (9:37): Yeah. When you look at that guy in the corner of the gym who's lifting, like, really big circles of weights and his face is turning red and it's, like, veins popping out his forehead, you're like, oh, intense.

Emily (9:50): I like your, like, old man growl. Oh, it's so intense.

Eva (9:57): Okay. But then we also have treatment duration. Right? So that's the length of time a magnitude is applied. So this can be within treatments or across treatments.

Eva (10:06): We're thinking about maybe like sustained holding of exercises or the number of times an exercises has to be done, how many days a week the exercise has to be completed. You get it. It's time oriented. Duration.

Emily (10:21): So this intensity and duration are important factors because different muscle activations can produce different results. And Yeah. When I like curl my biceps, my legs don't get stronger. Like that? Yeah.

Emily (10:40): Well, kind of. It can be like I I can very easily pick up my lunch and hold it for a second. But as soon as I have to walk down my very long hallway, my arms are screaming at me that I needed to walk just a little bit faster because my muscles are really working to carry this this thing now because it's different muscle kind

Unknown Speaker (11:03): holding the lunchbox while you're walking down the hall. Okay. Got it. Got it. Got it.

Unknown Speaker (11:09): Well, now we all know how Emily exercises at work. Well done.

Emily (11:13): It's all food related. My whole life is just circles around food.

Eva (11:17): Yeah. Sometimes I wish I could go to the rehab gym during lunch and lift weights, but they're all like two pound weights and that's not really what I'm going for. I was hoping for like a barbell.

Emily (11:27): Let's get into why this is a thing. So we're gonna get a little technical, so just, again, bear with us. So from the article, depending on the intensity and duration of the therapeutic stimulus, the metabolic pathways that will be accessed for chemical energy transportation in the body are different. So they're Get technical. I know.

Emily (11:52): It's it's the hardest part about these episodes is the technical parts. Okay. So basically, the body has three systems that produce energy. It's the adenosine triphosphate, otherwise known as ATP. And we're gonna keep calling it ATP because you can't pay me enough to try and say those words a bunch of times.

Emily (12:13): And this ATP is required for muscular contraction.

Eva (12:18): Yeah. No ATP. Your muscles don't contract.

Emily (12:22): These three systems produce very amounts of ATP at different rates and consist of an aerobic system, which supplies long term energy, and two anaerobic systems, which produce a lot of immediate energy but lose steam quickly.

Eva (12:38): Alright. So the ways in which we use our energy can either be long term energy supply or short term energy supply.

Emily (12:48): While all three systems are activated simultaneously, the relative contribution of each system to the process of producing ATP depends on intensity and duration of the exercise.

Eva (13:00): So even though we have, like, the one long term and the two short term, they're all going together. They're happening simultaneously.

Emily (13:07): And we need all three of them or carrying my lunchbox all the way to my office is going to be impossible. Even though it feels

Eva (13:15): easy I'm at suddenly wondering how heavy your lunchbox is.

Unknown Speaker (13:19): It's like actually embarrassing. I bring my whole home's leftovers to work so I don't have to carry so I don't have to pack lunch over multiple days. So that's

Eva (13:29): that's really heavy. But so it gets lighter throughout the week the more that you eat of it.

Unknown Speaker (13:34): But I I don't carry it back and forth. I leave it in the the gym refrigerator. The staff open So it's just Mondays. So I'm It's

Unknown Speaker (13:41): just Mondays.

Emily (13:42): Just suck. Maybe if I did carry a lunch every single day, then it wouldn't be so bad. But Mondays and like Thursday suck.

Eva (13:52): Mondays and Thursdays.

Emily (13:53): Okay. So the article states that training the anaerobic system was necessary to improve forceful muscular contractions or swallowing, whereas training the aerobic system or that long term is necessary to improve muscular endurance and maintain that forceful contraction over a period of time.

Eva (14:14): Got it. So it sounds like the things we're balancing are the ability to do forceful contraction and then the ability to maintain the contraction.

Emily (14:22): Exactly. So we need that forceful contraction over the whole meal.

Eva (14:27): It's like when I pick my kid up and I'm like curling her up to my chest and I'm like, oh, I got you. And then like five seconds later, I'm like, no. No. I can't walk with you up the hill. You gotta go down.

Unknown Speaker (14:39): I could get you up, but I cannot hold you, my dear.

Unknown Speaker (14:41): Right.

Eva (14:42): So it sounds like the article separates dysphagia rehabilitation programs in targeting efficiency of a swallow and the swallowing force or swallowing coordination to achieve increased safety. So we have efficiency on one side that's being targeted, and on the other, we have swallowing force slash coordination. Then further separated these into direct treatments or indirect treatments. Direct treatments? Such an important distinction.

Eva (15:12): I'm like really into direct versus indirect dysphagia therapy. And that may sound facetious, but for reals, I love it.

Emily (15:20): Direct treatments. Swallowing exercises in which the swallow is utilized in the exercise. So Mendelson, effortful swallow. And then indirect treatments, exercises that improve the overall musculature that impacts swallowing but doesn't require the swallow. Think Shakir, EMSD, LSVT.

Emily (15:42): Eva, what are some of your favorite direct swallow treatments and your favorite indirect swallow treatments?

Eva (15:49): My favorite indirect swallow treatments where we're just kind of like I think of indirect swallow treatments as like the going to the gym where you're like, we're doing exercises Mhmm. But it doesn't necessarily, like, said, involve swallowing. For, I guess, indirect treatments, I really like EMST or expiratory muscle strength training. I just think that building up enough force in the airway and improve it improve so much. It's both good for voicing, for sustained phonation, and it is so good for airway protection.

Eva (16:30): So big fan of that. And then for direct treatments, I really like effortful swallow. It just seems really natural. People seem to get it. They're like, I'm swallowing, but I'm swallowing hard.

Eva (16:44): I'm like, yep. Pretty much. Seems so achievable.

Emily (16:50): It does seem very achievable unless you're me, and then I have trouble conceptualizing that effortful swallow. These exercise take only one to two seconds, And these are going to be super similar to what you would be expected to do or what your muscles are expected to do during normal swallowing or a meal. So those direct treatments may be more desirable to the people completing the exercises because they just make sense. The intervention affects towards the same mechanisms underlying muscle contractions. Rewinding though a little bit, I

Eva (17:24): think that kind of is spot on with what, you know, we were trying to reflect just a minute ago that the direct treatments or direct therapies mimic a real swallow in some capacity. You you have to actually do a swallow. And so people, I think, are kinda going, oh, I can feel that I'm swallowing. I'm doing swallow therapy. And that makes sense to them.

Eva (17:45): Which as we know as speech therapists, a lot of people ask us when we do exercises, why am I doing this? So that buy in, that ideal that the therapeutic activity makes sense to the patient is fantastic Mhmm. In my in my humble opinion. But that's not to undercut, like, indirect treatments. Right?

Eva (18:08): We keep going back to the curling analogy at the gym because everybody knows that that is something you do to build up your arm muscles. Yeah, you could carry your lunchbox down the hall, three times a day, five times, you know, in five repetition sets. But realistically, we're not going to do that. More naturalistic exercises, while important, have in my, again, my humble opinion, limited function, you also have to kinda do that more indirect treatment that I'm just lifting weights. It's not as naturalistic as putting something in a shelf over my head.

Eva (18:45): Mhmm. But doing an overhead press with a barbell like, oh, I know what I'm doing. I'm building muscles. Right.

Emily (18:52): And the article talked about exercise programs more detailed for these indirect treatments. So following a lingual exercise prescription, changes in swallow outcome measures include reduced oral transit time and residue and improved penetration aspiration score. And then both LSVT and EMST. So

Eva (19:16): That's for people who don't know those acronyms, that's Lee Silverman voice training. Did I get that right? And respiratory respiratory muscle strength training, which are targeted both at kind of airway and projection. And they have other functions too, but it's a lot of

Emily (19:37): ah or Those treatments were looked at, and they were very easy for people to understand and utilize because they use a strict intensity and duration parameter. So and they also said that they resulted in physiological changes to the swallowing mechanism. Okay.

Eva (19:57): So it sounds like what they're doing in this article is in part just verifying the functionality of some of these exercises. They're like, look, LSVT, EMST. When you use the the prescribed dosage of intensity and duration, we can measure these specific physiologic changes, which get backs gets back to the idea of do we learn correctly how to do dysphasia treatment? And these exercises were developed in very particular regimens. It's not like somebody did a chin tuck swallow and was like, oh, I did it one time and maybe it worked or somebody did a, you know, a muscle strength training exercise for, you know, something in the pharynx and they were like, you do it once.

Eva (20:46): It's fine. No. The research that supports these is based on very specific parameters. And in order for to see the results, you gotta do those parameters. Mhmm.

Emily (20:57): So what are our parameters? How much exercise is enough exercise to make a meaningful difference?

Eva (21:05): Okay. Just quick pause. I like that question. What what do we need to be doing to make a meaningful difference? So that doesn't say what is the most exercise we can do, and it doesn't say what is the most perfect swallow we can do.

Eva (21:19): I think the way you phrased it is incredibly functional. How much exercise do we need to do to make a difference in somebody's life?

Emily (21:27): Based on the review of the study findings, it can be summarized that no less than two weeks of treatment delivered three to five times per week can be recommended with a reasonable expectation for improvement.

Eva (21:42): Okay. Minimum of two weeks, three to five times per week. That seems achievable.

Emily (21:49): And then for motor focused treatments, a minimum of four weeks of treatment should be targeted before a function can be expected to improve significantly. And what I like about that is

Eva (22:01): you need your patients to believe that this is gonna work and being able to give them a time frame is probably really helpful. If you're only seeing them for a week and they're going, this isn't making a difference. Why do I have to do this? I'd much rather be resting. I'm tired all the time.

Eva (22:19): Saying, hey. We gotta keep this up for a month. That's when we can

Emily (22:22): start to see changes. And giving them that treatment prescription, so to tell them how long we're gonna be doing that, when you can expect to see outcomes, it's going to improve your buy in. If if people know that they're not expected to see actual changes for four weeks, they're not coming to you on day two like, I don't feel different. Like, you will, Shirley. Just give me some time.

Eva (22:48): Told you don't call me Shirley. Yeah. And I think this just gets back always to the idea of patient education. So often clinicians are walking into a room and being like, do x, y, and z. Goodbye.

Eva (23:01): Part of what we need to be educating people in is this is your primary diagnosis, like why you came here. This is your clinical diagnosis. Like, this is what I'm treating you for. Here's how these things are related. If they're related, hopefully they're related.

Eva (23:16): This also goes back to goal building. As clinicians, we have to build short term goals to go into long term goals. Your short term goals ideally should be achievable within a week or two. So if you're long term, your five week goal for a patient or your four week goal for a patient is that they're gonna have improved swallow function, don't don't get too down on yourself each of those first couple weeks. They are making progress.

Eva (23:42): You just may not be as easily observable and we now know this because, dun dun dun dun, may take a minimum of four weeks of treatment for a function to improve significantly. And just to give an idea of some of like the frequencies, total treatment time, so on and so forth for these various exercises, we're just gonna dip into a couple of these. I feel like this is a little bit juicy because, for example, things like the Shakir, I hear recommended all the time. You have to for the Shakir to be considered effective. Right?

Eva (24:18): Because these are the parameters they were built on. The Shakir head raise has to be done for six weeks, seven days a week, three times a day for a length or repetition of three sustained and 30 repetitive head raises for a total amount of 378 sustained and 30 repetitive iterations. So holy smokes, that's a lot. That's like if you're doing the shakir with your patient like five times, a few times a week, it's not cutting it. On the other hand, there were ones that were, you know, in some ways easier.

Eva (25:04): For example, some lingual exercises, tongue exercises. You only have to do them three days a week, but you gotta do it for eight weeks, three times a day, 30 times for a total of 2,160 repetitions. So you're kind of getting an idea of maybe we're recommending exercises to our patients, but the dosages are not necessarily compliant with what the research was built around them for. And that's okay. I can't imagine that doing them 10 times is just as bad as not doing them at all.

Eva (25:49): Right? It's like, I'd rather you brush your teeth once a day than never brush teeth. Right? I'm sure it's making some kind of difference. But think about the intensity that we're we have to do these treatments for them to definitely per the guidelines be considered effective.

Eva (26:07): And how often we're actually recommending it to patients, that timeline of, like, eight weeks of therapy exercises for, you know, tongue strengthening might start to look more like, you know, five months if you're doing it at half that frequency or inconsistently. And that really changes how our patients may perceive their success in their own therapy. And is So there's trade offs.

Emily (26:34): Is it even going to be effective if we're taking so long to do those exercises? Like if the recommendation is to get these within eight weeks and we're taking that five months, like are we reasonable in telling our patients, like, we can see progress if we're not pushing them to do as many repetitions as they need to?

Eva (26:59): Yeah. And that patient buying is really important. If somebody's like, okay, in eight weeks, if I do this for eight weeks, I'll see benefits. Two months, that's a while, but that's manageable. You might might see improvements in five or six months.

Eva (27:21): Hard to get people to wanna commit to that. So yeah, I think that table was tasty.

Emily (27:28): Okay, Eva. So, like, realistically, how would you work at increasing repetitions in a sniff session without it feeling overwhelming to you or the patient?

Eva (27:43): That is such a good question because my first reaction was, wow. At the hospital, that seems really feasible. You know, we are scheduled five days a week, guaranteed. Otherwise, in the acute setting, their stay isn't we're not gonna get reimbursed. So we really work hard.

Eva (28:01): Otherwise, all the effort we've put in, we don't make any money on, which it's not about the the bottom line, but it is people need to get paid in their salaries. Right? So, yeah, at the hospital, that seems very feasible. I feel very supported in the amount of direct time I get with patients. The environment is conducive to learning kind of more technical or difficult exercises.

Eva (28:27): However, in the Smith, in skilled nursing, I would say that it's really hard and going back to that Instagram joke I made at the beginning of the episode, maybe only two exercises would be feasible at this intensity level. Mhmm. Honestly, maybe only one. Depending on the patient, what they're capable of doing, what kind of support they may need. You know, getting in to do a clear thirty minute session with a patient is so difficult, and I think you would have to be so smart about it.

Eva (29:06): By the way, if our max length of stay for a patient is, say, like three to four weeks, we have to get it so ingrained into them to do these activities such that they continue to choose to do it on their own when they go home.

Emily (29:20): Mhmm.

Eva (29:20): You know? And if we're not dosing them accurately, then they're not seeing the benefits, then they are not gonna wanna do it when they go home, which means they won't ever make those gains. You know? So it's just one of those classic cascading effects where you're trying to make improvements in this person's swallow function. But if you can't do the exercises correctly, they won't make those gains.

Eva (29:47): So we have to really set ourselves and our patients up for the success of doing it correctly. Yeah.

Emily (29:53): So for me, some of the ways that I help increase some of the reps because that like, this is what I do for my my swallowing patients. Like, we are working. And I set it up just

Unknown Speaker (30:05): We're king. Working.

Emily (30:07): I set it up kinda the same way my exercise instructor does. Like, we go between different muscle groups. Right? Like, we're not doing the same exercise at mass. We're switching.

Emily (30:21): Doing maybe some shakirs, and then we're gonna go to lingual exercises or labial exercises and then back to those swallow muscles in your throat. So we're switching back and forth and back and forth and back and forth so that one set of exercises doesn't feel like it's so overwhelming or you're just dying from doing all of those at one time.

Eva (30:47): Yeah. And what I like about that is it translates well with, their other therapies. You know? PT or OT has got them doing sit to stands. Right?

Eva (30:57): They're learning those sequences. They're learning those transfers. They They go down to the rehab gym. You gotta lift this weight x number of times. And for people, I think that context of this is an exercise.

Eva (31:09): We're doing sets and repetitions keeps them attuned to the idea of this is exercise. You know? And while the while the exercise and while the research article talks about parameters of sets and repetitions, there's also the important parameter I think of defining swallow exercise time. Right? It's like, hey.

Eva (31:32): You and I are here. We're gonna lock in for ten minutes, and we're gonna do these exercises. Then you're done. You know? And just making this as direct as possible, as engaged as possible.

Emily (31:41): Yeah. That's a good point too. In the article, they talked about those short, more frequent time slots. So ten minutes across your day. So three times during that day, we'll stop in in the morning.

Emily (31:53): Alright. Let's do some effort pulls. Go back. Time for your effort pulls. And then one more time before you leave to make sure they're getting all sets across the entire day.

Eva (32:05): Yeah. And I think that really speaks to the art form of balancing your time. You know? I know I had initially said, well, at the hospital, that sounds really feasible, but I may be seeing them for an hour long session and they're not gonna have any more speech therapy for the rest of the day. So they either have to be with it enough to use a schedule or alarms or just know that they're gonna do this before or after every meal, which is usually what I recommend people.

Eva (32:31): So I'm like, hey. You eat three times a day. It's a great opportunity to do your exercises before or after. But if I'm not there, then I can't do it. Whereas at skilled nursing, I can pop in multiple times because I don't have that scheduled structure.

Eva (32:46): So it's the pros and cons of the fluid of the fluid nonstructured time at skilled nursing.

Emily (32:51): Have you done anything that's actually improved carryover?

Unknown Speaker (32:57): That's a really good question. Or compliance

Emily (33:00): or, like, actually got people to do their exercises?

Eva (33:04): I think that something I've seen since the hospital is since working at the hospital is using trackers. So before I used to track for my patients. Mhmm. Like, this is how many times we did it. It was in my notes.

Eva (33:18): But now we have binders in all the patients' rooms, which little, like, moment of self validation. I kept trying to push for that in skilled nursing. Was like, people don't remember what we're teaching them. They need binders with their exercises, and I could just never get it done unless I wanted to start buying it all myself.

Unknown Speaker (33:36): Mhmm.

Eva (33:37): And I got to the hospital, and they were like, well, you should know that all of our patients get binders so that they can remember their exercises. And I was like, I knew this was going to be useful. So I would say that if you can get people to do their own tracking, that is it. They have to understand that it is something that needs to be scheduled. And once you have trained them in using their their planner, that is the best way to do it.

Eva (34:07): Because if you can we keep going back to the gym analogy, but, yeah, if you can only do your exercises in front of your instructor, then you can't do them at home. Mhmm. You know? And that you know, it is what it is.

Emily (34:23): Yeah. And bringing it back to that tracker, we do have an accountability calendar on our website. So if you guys haven't checked you haven't seen that, go check it out. It's for me, it's the only way I've actually been able to get my patients to remember, understand, and do their exercises. So Yeah.

Unknown Speaker (34:44): Do it for

Eva (34:44): your patients and maybe do it for yourself. What do you need to be accountable for? I would say quickly, we're returning back to your question. I do have pages that I print out that explain plan of care to my patients. So that way even if I only get to see them for a week before they're discharged, they have all that information.

Eva (35:07): And while I can't guarantee that they are doing it when they go home, it's the thing that I feel best about for ensuring that I did everything I could to make sure that they understand why I have clinical concerns about their eating and swallowing, what I'm recommending they do to fix it, and how they can do that going home.

Emily (35:27): Yeah. So I always appreciate getting those from the hospital too. Like, Oh, heck. Yeah. Hospital will send not all the time.

Emily (35:35): I have and I don't even think that's a hospital thing. It's what however things get transferred from hospital to SNF and go into the ether or ether of nothingness that just gets lost. But when when a patient comes to our facility and they have all of those things all placed together in a binder or something that says the things that they had been working on or the things that they did do, it is so nice because I'm not having to retrain everything. I can just start wherever the last person left off and continue providing that education so we're not overwhelming them with more information or overdoing it or we're just continuing a previous set plan of care.

Eva (36:19): A lot of times, recommend to coworkers, SLPs, colleagues from other disciplines, what works for you likely works for your patients in in broad strokes. And that when I go to a pediatric appointment for my kid, they ask me a bunch of questions. I answer them. Then they tell me a lot of stuff and they go, do you have any questions? I say, no.

Eva (36:43): And then I leave the room and I'm very confused. I remember nothing they told me. Right? You should expect your patients to feel the same way. So if your doctor or your kid's pediatrician gives you handouts and you find that helpful, you should be providing those to your patients.

Unknown Speaker (36:59): I love a good handout.

Eva (37:02): Love a handout. We love a chart. We love a handout. We love a method section that just really gets at the heart of what a problem is.

Emily (37:10): So they talked about sensory interventions as being applied in research, but they haven't shown a lot of actual therapeutic benefit.

Eva (37:22): Okay. That's interesting. So it sounds like increasingly there is data to show support for motor based exercises for dysphasia, but the sensory one, we're still looking for more conclusive data. Yeah. Which again, I think we do a good job of highlighting in this podcast.

Eva (37:42): Doesn't mean you should rule it out. If you put a lemon glycerin swab in somebody's mouth and they go, yuck. That's gross. I'm awake and now I'm more ready for dysphasia therapy. I'm like, okay.

Eva (37:52): Yeah. Go for it. So find what works in your practice and that's fantastic. But also being more aware of just saying off the bat, this person has lower oral stimulation. I'm going to just because I've heard of these sensory stimuli activities do them.

Emily (38:11): Yeah. And I, I've, in my personal practice, I do sensory stimuli in my direct swallow treatments. So I am having people effortfully swallow peanut butter crackers. Right? For me, it's really hard to conceptualize a hard swallow.

Emily (38:31): Or I'll work with people using specifically sour Paparax. I don't know if you guys know that's a thing, but I'll have them eat

Unknown Speaker (38:40): Sounds terrible to me.

Emily (38:42): Oh my god. It's so yummy though. So you eat the sour Pop Rocks and you swallow them and you kinda just listen and feel that sensation of them still popping in your throat. And you just keep swallowing and swallowing and swallowing until that's gone. Again, we're using that effortful swallow, but having a sensation of that feeling in your throat helps bring attention to the muscles we're actually targeting.

Eva (39:08): This is the greatest advertisement for Pop Rocks I have ever heard. Clinical Pop Rocks brought to you by Speech Talk.

Emily (39:17): So I know. And it is they're they're fun exercises. And while, you know, I can't I can't stand behind the sensory thing in full, I will be doing a short video segment on how to do some of these exercises. And you can check that out on both our YouTube page and our Instagram.

Eva (39:40): We're we're really trying with social media, everybody. If you haven't got the

Unknown Speaker (39:44): If you don't

Unknown Speaker (39:44): follow us on Instagram, please do.

Emily (39:47): To wrap things up, this article emphasizes the need to use motor based perspectives to target swallowing therapy with clear and measurable intensity and duration to optimize performance. Clear and measurable. When setting up a therapy dosage using direct treatment and indirect treatments to get at both of these energy expenditure systems. And finally, advocating for longer treatment times or shorter, more frequent visits or even more home training to increase patients' independent swallowing therapy work.

Eva (40:23): Break up your therapy how you need

Unknown Speaker (40:24): to to get it to work. And fight for it. Fight for your time.

Eva (40:28): Yeah. Boxing gloves. Be yeah. Aggressive. No.

Unknown Speaker (40:32): I'm not an

Emily (40:32): aggressive person. Aggressive. So, again, everybody, let us know if you are using specific treatments in your practice. Let us know. If you have gone through dysphasia treatment and liked it or didn't like it, let us know.

Emily (40:47): If your family is going through dysphasia something and you are trying to do

Eva (40:53): those You should ask what their dosage is.

Emily (40:56): Ask ask questions. Now go to your therapy sessions and ask your speech therapist some questions.

Eva (41:01): That's right. Alright. Keep doing the reps. We'll keep bringing the research. Thanks, guys.

Unknown Speaker (41:09): You've been listening to Speech Talk.

Eva (41:11): Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research. If you like this episode and you wanna give us some love, please rate us

Emily (41:21): on your favorite podcasting app. Leave a review and tell the world because as podcasters, our love language is in positive affirmations.

Eva (41:29): And if you like listening to us, you may like more podcasts from our network, human content, like how to be patient, bendy bodies, knock knock high with the glock and pluckens, and psychiatry boot camp. If you have a research topic you want us to cover or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hellospeechtalkpod dot com.

Unknown Speaker (41:53): If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more. We're your

Eva (42:06): hosts, Eva Johnson and Emily Brady.

Emily (42:09): Our editor and engineer is Andrew Sims. Our music is by Omar Benzvi. Our executive producers are Erin Corney, Rob Goldman, and Shanti Brooke.

Eva (42:18): To learn about Speech Talks program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com/disclaimers.

Unknown Speaker (42:30): Speech Talk is a proud member of the Human Content Podcast Network.

Unknown Speaker (42:49): Pandora jewelry brings the sparkle to your summer now with even better prices. Enjoy up to 50% off select styles from personalized pieces to must have favorites made for the summer. Timeless designs that shine with you through every moment, wherever the summer takes you. Shop in store or online now through July 6. Terms and conditions apply.

Unknown Speaker (43:10): Visit pandora.net for details.

Speaker 3 (43:15): This episode is brought to you by Google Chrome. You think you know a browser, but Gemini in Chrome, That's new. It can help you with practically anything on the web, like restoring a vintage motorcycle from a 50 page restoration block or finally break down that long article you've had open for weeks. Gemini and Chrome is here for it. Ready to make anything online make sense?

Speaker 3 (43:34): There's no place like Chrome. Check responses, setup required, compatibility, and availability varies 18 plus.

Unknown Speaker (43:45): Human content.