Specific information regarding the Communication Sciences and Disorders' Acute Care Speech Language Pathology practicum led by Carley Evans MS CCC SLP. Carley is a medical speech pathologist at the Evelyn Trammell Institute for Voice and Swallowing of the Medical University of South Carolina in Charleston. If you are new to this practicum, start with the oldest post listed in Archive.

Friday, February 29, 2008

Neoesophago-tracheal Fistula After Esophagectomy For Cancer

Rather rare, but...
"after esophagectomy for cancer a fistula developed between the trachea and the pulled-up stomach because of the ischaemic effect of the tracheostomy tube. At single stage repairs, the fistulae were divided and the gastric defects were closed directly...Treatment of this potentially life threatening and rare condition yielded excellent results."

Source: Kalmar et al. "Non-malignant tracheo-gastric fistula following esophagectomy for cancer."

Wednesday, February 27, 2008

Ivor Lewis Esophagectomy

The esophagus is a hollow tube that moves food and liquids from the throat to the stomach. It is located just behind the trachea (windpipe) and, in an adult, is about 10 inches long. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle and connective tissue.

Esophagectomy is the surgical removal of part of the esophagus. The lower part of the esophagus and upper part of the stomach (fundus) are removed and the remaining parts are then connected to re-establish the digestive tract.

Reason for an Esophagectomy
Esophagectomy is the treatment of choice for esophageal cancers.

The Ivor Lewis Esophagectomy
The Ivor Lewis is a specific, two-stage surgical approach esophagectomy. The first stage is through an incision in the abdomen to “free up” and remove part of the stomach. This section of stomach will be formed into a replacement esophagus. The second stage is done through an incision in the chest to remove the diseased part of the esophagus, insert the newly formed esophagus, and re-attach the esophagus to the remainder of the stomach. The procedure takes about 5 hours.

The Ivor Lewis procedure is used for those who have tumors in the middle or lower third of the esophagus.

Thursday, February 14, 2008

Not Necessarily Turning A Dead Horse Into A Rug: More On Vital Stim

With all due respect, and at the risk of turning the dead horse into a rug, the meta-analysis published by Carnaby-Mann and Crary, used excessively lax inclusion criteria, rendering the results very difficult if not impossible to generalize to the clinical setting. Here is one set of examples to support this comment, and there are several others that the discussion group certainly does not want to hear.

A meta-analysis is only as good as the criteria for allowing studies to be included. They need to be rigorous.

The use of the Physiotherapy Evidence Database scale (PEDro) scale for judging evidence quality, at a cutoff score of 4 on the scale, allowed studies such as Freed, et al. (2001) (we all know which study that was and all of its problems-it is only one example from this meta-analysis’s included studies), to be included in the meta-analysis. Freed et al. (2001), as we all are aware, a) violated intention to treat with 10% of their patients disappearing from the data analysis for unexplained reasons or because they could not pay for the treatment after insurance terminated coverage(PEDro item 9), used judges that were not masked to patient assignment (PEDro item 6 and 7), selectively assigned patients to electrical stimulation “because they were referred for the study” (PEDro items 3 and 5), compared dissimilar groups of heterogeneous patients and excluded patients for unexplained reasons (PEDro item 4), and did not randomly assign patients to groups (PEDro item 2). In addition the study was conducted by the owner of the patent for the technology investigated, a serious conflict of interest not even acknowledged as an important criterion for evidence quality assessment by the PEDro. These serious flaws notwithstanding Carnaby-Mann and Crary included this, and several other studies of poor evidence quality, in their meta-analysis. The results must be considered weak and ungeneralizable to the clinical setting, at best, given the inclusion of poor quality studies.

Meta-analysis is an effort to use the best literature available to answer important questions about cause and effect. This study did not accomplish that goal. The lack of good quality studies does not justify the use of poor quality studies to make important decisions about treatment effectiveness or efficacy. It is always possible for a faction to cherry pick results from various studies to support their point of view. That is not what meta-analysis is about. This is why Vioxx was such a colossal failure.

James L. Coyle

University of Pittsburgh

Wednesday, February 13, 2008

Thinking of Patients As Your Own

Of course, there is a caveat. Sometimes, we may be going to ART or MUH to see patients who normally may or may not be on our caseload. Therefore, expect to be flexible in your plans.

Vital Stim Research: Questions and Answers

There were several interesting findings from Dr. Ludlow's study looking at the effect of applying NMES to the anterior portion of the neck, including the improvement in swallowing from sensory stim alone that Dr. Day mentioned. Another outcome that is often not mentioned is the unexpected finding that the patients who had greatest hyoid depression had the greatest improvement in swallowing. I would be interested to see future research looking into the cause behind this counter-intuitive finding. While these findings could possibly suggest a positive effect from using NMES during tx, as the authors point out, this is not a treatment study but an effect study. Therefore, conclusions should not be made, either positive or negative, about the impact these findings may have on treatment.

Instead, we should make conclusions about treatment based on treatment studies. One study worth noting is Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg. June 2007; 133 (6): 564-571.

With regards to the question "where is research on chronic dysphagia (1 year post)?"asked in an earlier posting , look for Dr. Carnaby-Mann and Dr. Crary's study "Adjunctive neuromuscular electrical stimulation for treatment refractory dysphagia: A phase I case series report" which will be published in the Annals of Otology, Rhinology & Laryngology soon. The patients in this study were an average of 5 years post onset.

With regards to any research, rather than focusing on the source of funding, I believe it is more productive to critically read the entire study, look at the research methodology, and then make decisions about if the the findings are applicable to what we do in treatment. Again, we should agree to disagree on what conclusions we will each make.

The debate about using NMES in swallowing tx has been good for our profession in that it has challenged us to look at the research behind what we do as clinicians. The caliber of research that we are requesting about VitalStim (randomized controls, studies that account for the possibility of spontaneous recovery) should be sought for all our therapies.

Jen Carter, M.Ed., CCC-SLP
Clinical Specialist, VitalStim Therapy

Tuesday, February 12, 2008

Cocaine and Amphetamine Abuse Increases Stroke Risk

Content provided by Health Day
MONDAY, April 9 2007 (HealthDay News) -- The abuse of stimulant drugs such as cocaine and amphetamines may increase the risk of stroke by raising blood pressure or triggering spasms in blood vessel walls that contribute to the narrowing of the vessels, a U.S. study says.

Researchers analyzed data on patients treated for stroke or drug abuse at Texas hospitals between 2000 and 2003. They concluded that amphetamine abuse was associated with a fivefold increased risk of hemorrhagic stroke (bleeding in the brain), but not ischemic stroke (blocked blood flow to the brain).

They also found that cocaine was associated with a greater than twofold increased risk of both hemorrhagic and ischemic stroke.

In addition, amphetamine abuse, but not cocaine use, was associated with a higher risk of death after hemorrhagic stroke, the study authors said.

"The public health implications of these findings are heightened by growing news accounts suggesting a recent increase in methamphetamine abuse, particularly in the southwestern, western and Midwestern states," they wrote.

"This concern was supported by our finding that, among hospitalized patients in Texas from 2000 to 2003, the rate of amphetamine abuse was increasing faster than that of any other drug, including cocaine, and the rate of strokes among amphetamine abusers was increasing faster than the rate of strokes among abusers of any other drug."

The study is in the April issue of the journal Archives of General Psychiatry.

Monday, February 11, 2008

Two Weeks Before Mid-Term

Two weeks before mid-term:
Time to start thinking of the TCU patients as your own. This, obviously, means knowing them. (If you need the daily patient sheet, I will happily print it for you. Just make sure the patients' names and MRNs are blacked out or cut off the page before you take it off campus.)

Come to clinic relatively prepared with these three questions in mind: e.g. which patients, what deficits, and with which treatment tasks?

Take a little time when you first arrive to select materials, then let's head out to your first patient. Remember, of course, that patient may not be available so be prepared to move on to another.

Thermal Tactile Stimulation

Thermal stimulation or thermal-tactile application has been investigated quite a bit and has largely been dismissed as it has been shown to produce only momentary and non-durable reductions in stage transition duration (pharyngeal delay time) (Hamdy et al., 2003; Miyaoka et al., 2006; Rosenbek et al., 1998; Rosenbek, Robbins, Fishback, & Levine, 1991; Rosenbek, Roecker, Wood, & Robbins, 1996). It is receiving more thought recently due to current questions about the role of sensory input on neuromuscular plasticity in adults with neurological diseases and stroke.

James L. Coyle
University of Pittsburgh


Hamdy, S., Jilani, S., Price, V., Parker, C., Hall, N., & Power, M. (2003). Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury. Neurogastroenterology & Motility, 15, 69-77.

Miyaoka, Y., Haishima, K., Takagi, M., Haishima, H., Asari, J., & Yamada, Y. (2006). Influences of thermal and gustatory characteristics on sensory and motor aspects of swallowing. Dysphagia, 21, 1-11.

Rosenbek, J. C., Robbins, J. A., Fishback, B., & Levine, R. L. (1991). Effects of thermal application on dysphagia after stroke. Journal of Speech and Hearing Research, 34, 1257-1268.

Rosenbek, J. C., Robbins, J. A., Willford, W. O., Kirk, G., Schiltz, A., Sowell, T. W. et al. (1998). Comparing treatment intensities of tactile-thermal application. Dysphagia., 13, 1-9.

Rosenbek, J. C., Roecker, E. B., Wood, J. L., & Robbins, J. A. (1996). Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia, 11, 225-233.

Thursday, February 7, 2008

Lateral Medullary Stroke (LMS)

James Coyle writes:
a lateral medullary stroke (LMS). These strokes damage the important brainstem nuclei that mediate sensory and motor functions in the pharynx as the interconnections between them and other centers. Immediately prior to pharyngeal stage onset the UES resting pressure is seen to drop a little, due to inhibition of the vagal motor outflow to the sphincter. This tight, resting pressure keeps the UES tightly closed all of the time except when we swallow. In LMS the patient may have no inhibition of UES resting pressure, hence the h yolaryngeal musculature cannot overcome the intertia of the tight UES.

One clue is the side to which bolus flow is preferential. You said right. If this is true then the right pyriform sinus is more compliant than the left. Provided that you have trained him in airway protection maneuvers, head rotation might be worth assessing. I would expect that rotation away from the compliant side would facilitate flow to the more compliant side, but you cannot always predict this outcome based on lesion site knowledge because if an upper motor neuron lesion has produced denervation of the hypopharynx you will have a spastic paresis and less compliance, while a flaccid paralysis caused by a lower motor neuron (nucleus or nerve root) lesion will make the sinus more compliant. You will need to evaluate it provided it is safe to do so based on airway protection ability.

...Nearly 90-95% of the dysphagia seen in most patients with LMS resolves to a functional swallow or one that can be compensated with intervention.

James L. Coyle

University of Pittsburgh

Billing Issues to Ponder

Medicare Part A recognizes concurrent therapy - treating more than one patient at one time on separate tasks / goals (sometimes called "dovetailing") AND group therapy - treating 2 to 4 patients at one time working on the same tasks / goals for the same time. For concurrent therapy, if both patients were in the session for one hour, they might be billed for up to one hour of individual treatment. If there were 4 patients in a group for one hour, all 4 patients would be billed for one hour of group. In the SNF environment, group therapy minutes are limited to 25% of the total treatment program for each discipline during the last 7 days (minutes recorded on the MDS).

Under Medicare Part B - which would cover outpatient therapy - concurrent therapy is not recognized and must be either billed as group or the time must be divided according to how the attention of the therapist is divided. Patients may participate in a group as defined above as well. There is no CPT code to reflect group therapy for dysphagia under Medicare Part B. 97150 is the code used by PT or OT,
92508 is the code used for speech/language/cognition intervention in a group.

Wednesday, February 6, 2008

Training Yes and No Responses

With some aphasias, yes and no responses may be unreliable. The person may nod negatively while verbalizing 'yes' or 'yeah' or 'okay.'

To train differentiation of the affirmative from the negative, show 4 pictured objects (e.g. hammer, saw, screwdriver, scissors) and tell the person "I am going to ask you a set of questions all of which you will answer with a "yes" and a head nod." Demonstrate this. Then point to 1 (i.e. hammer) of the 4 pictured objects, asking, "Is this a hammer?" The patient should say "yes." If so, verbally indicate that this is right. If not, then demonstrate the appropriate response. Continue.

After "yes" is established, switch to "no." Give the same instruction. "I am going to ask you a set of questions all of which you will answer with a "no" and a head nod." Demonstrate this. Then, take the same 4 pictures, point to the hammer as before, but now ask, "Is this a screwdriver?" If the person answers "no" praise and verbally indicate that is correct. If the person says "yes" then demonstrate the proper response. Continue.

Track percentage correct and establish 100% differentiation between yes and no responses with this sort of questioning.

Move to personal information or immediate situation yes no questions once you have an established differentiation.


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