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I don’t know, what do YOU think?

Mr. McMahon was my 10th grade English teacher. Everyone constantly griped about his class, so I was less than excited to start the semester. He had a way of teaching that was considered unorthodox and challenging. Mr. McMahon could conduct a whole class on the ‘Great Gatsby’ text in no more than seven words – “I don’t know, what do YOU think?” Each class was like a ping-pong tournament; when Student ‘A’ in the back of the class had a question about the text, it got deflected to Student ‘B’ in the front of the class, then Student ‘B’ would give a partial answer and come back with another question that got deflected to Student ‘C’. And so it went on… “I don’t know, what do YOU think?” Soon the class would start answering each other’s questions and occasionally our teacher would give us a certain look to indicate if we were on the right track. I am convinced one of the joys for Mr. McMahon was seeing the bewilderment and inquisitive faces of his students, but only because he knew real thinking was taking place.

Reflecting back on this helped me realize that anyone could learn to take a test on the ‘Great Gatsby’ text, but how many were truly able to think critically about it?

The above scenario does not do justice, but hopefully sheds some light on the type of course that ‘Critical Thinking in Dysphagia Management’ (CTDM) turned out to be in San Francsico, on July 16, 2016 – with Dr. Ianessa Humbert filling in as our Mr. McMahon for the day.

In order to arrive at a ‘sweet spot’ in therapy, we need to understand the impairment, decide if we want to challenge that impairment or facilitate it, and then choose the appropriate strategy to do so.

The CTDM course held at the University of California San Francisco Medical Center included attendees who were speech-language pathologists and clinicians from every level of experience; from current graduate students who were yet to take a dysphagia course and fresh clinical fellows to more senior clinicians and supervisors. While an overview of the course can be reviewed in a previous Dysphagia Cafe post from Rinki Varindani Desai, this piece aims to highlight a specific topic that was discussed in the course, which really stood out.

Shedding light on compensatory strategies

While dysphagia management should be anything but cookie-cutter, most clinicians may benefit from utilizing a framework or decision tree to make sound clinical decisions.Most clinicians should be familiar with a table in the Logemann text (1998) that lists the following information regarding the use of postures/compensatory strategies:

  1. Disorder observed on videofluoroscopy
  2. Posture applied
  3. Rationale for applying

What’s not to like? A simple recipe provided to bake the perfect cake! Few can question the effectiveness of compensatory strategies, when used with the right patient in the right situation, to modify the swallowing mechanism in some way and provide a safe means of oral intake. However, do compensatory strategies endorse lasting change? Are principles of neuroplasticity being utilized to promote lasting change in the swallowing mechanism? To explore this further, Dr. Humbert proposed the question – Can we use compensatory strategies to ‘challenge the swallow’?

In order to answer this question, the attendees at the course wrestled with the following principles of neuroplasticity (Robbins et al., 2008):

  1. Use it or Lose it: Inactive parts of the brain may degrade
  2. Repetition: Frequent brain activity matters
  3. Intensity: Pushing the limits beyond a typical level of activity
  4. Specificity: Task-specific approach improves performance of task
  5. Salience: Motivation may improve performance of a task
  6. Difficulty: Improvement might not take place if area of the brain is not challenged
  7. Transference: Generalization to other behaviors may take place with plasticity

Traditionally, in disciplines such as occupational therapy, there is a commonly used technique called ‘Constraint-Induced Therapy’ – Constrain the good arm and challenge the patient to use the bad arm to promote change. By utilizing compensatory strategies ever so often, are dysphagia clinicians constraining the proverbial bad arm and using the good one instead? Perhaps, there are ways to go beyond a table or checklist to utilize compensatory strategies to challenge the swallow, thus taking the cast off the bad arm. For example, here are four strategies in their more familiar form (that constrain the bad arm):

The familiar checklist tells the clinician –

  1. Chin down posture is used for reduced oral bolus control. The posture widens the valleculae and prevents aspiration.
  2. Chin-up posture is for reduced posterior propulsion of the bolus by the tongue. The posture utilizes gravity to clear the oral cavity.
  3. Head Turn to the Left: Closes off the weak left side of the pharynx/pharyngeal wall
  4. Head Turn to the Right: Closes off the weak right side of the pharynx/pharyngeal wall.

Challenge the swallow!

Dr. Humbert encouraged us to think of rehabilitation and compensation not as two different therapy categories to improve the swallow, but as different elements along the same continuum of care. Thus the concept of “Challenging the Swallow” was introduced. This was essentially illustrated as turning compensation techniques into rehabilitative frameworks.

The following examples utilize the same compensatory techniques mentioned above, but use them in the opposite manner, thus turning compensation into rehabilitation. Specifically highlighted in the following examples are the principles of Intensity and Difficulty:

  1. Use the chin-down for reduced posterior propulsion – Challenge the swallow!
  2. Use the chin-up for swallow onset delay – Challenge the swallow!
  3. Turn the head L to use the weak R side – Challenge the swallow!
  4. Turn the head R to use the weak L side – Challenge the swallow!

I’ll admit, I wrote these examples down in a hurry with underlines and asterisks. Perhaps I got caught in trying to capture the golden nugget of the course, the proverbial “takeaway”, the shiniest tool in the toolbox. Well then, I guess I was missing the point…

The Sweet spot

As one slide on the presentation illustrated – In order to arrive at a ‘sweet spot’ in therapy, we need to understand the impairment, decide if we want to challenge that impairment or facilitate it, and then choose the appropriate strategy to do so. This way, we test the limits of the system, rather than limiting the system, to arrive at a “sweet spot” of dysphagia management. Are we limiting the abilities of the swallowing system to reach its maximum potential by too often handing over the crutch of compensation?

Surely, the purpose of this course was not to arrive at a takeaway ‘sweet spot’! This discussion was not meant to just talk about head turns and chin downs. This course demonstrated the possibilities (and importance) of challenging traditional questions. Were all our questions answered? No. Were some of our questions answered? Yes. Was traditional thinking challenged? Yes. Did I take home a new therapy tool to share with all my coworkers? In the wise words of Mr. McMahon, “I don’t know, what do YOU think?”

Links of Interest

  1. Swallowing Systems Core
  2. Bio for Dr. Ianessa Humbert

About the Author

Jonathan Waller, MA CC-SLP, founded Dysphagia Café in 2013. Dysphagia Café is a global resource community for the Dysphagia Clinician to learn and collaborate about old and new ideas for the benefit of our pediatric and adult patients with dysphagia. The focus is on generating and sharing original content from global leaders in dysphagia research and practice. The hope is that this is a positive and reliable place to share quality evidence-based content. If you would like to contribute to Dysphagia Café, please visit our support page. 

References

  1. Logemann JA. Evaluation and treatment of swallowing disorders. 2nd ed. Austin, TX: PRO-ED, Inc.; 1998.
  2. Robbins, J., Butler, S. G., Daniels, S. K., Gross, R. D., Langmore, S., Lazarus, C. L., Martinn-Harris, B., McCabe, D., Musson, N., & Rosenbek, J. C. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of speech, Language, and Hearing Research, 51, S276–S300.

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