Last year I had the honor of developing and presenting an on-line course with my colleagues from Calm, LLC to educate clinicians about the use of adaptive equipment (AE) in skilled-nursing facilities (SNF) targeting dysphagia management. Admittedly speaking into a green light on my computer took some getting used to in addition to navigating on-line meeting tools. It was a tremendous learning experience in several ways. We discussed an array of information including multidisciplinary evidence-based practice supporting AE use to manage dysphagia (Ney et. al 2009), state and federal laws advocating and regulating AE use (specifically F-Tag 369) and a variety of AE to manage common challenges (click here to read an earlier blog about the laws and research supporting AE for dysphagia management). We received a few questions after our course about the relationship between OTs and SLPs asking who is responsible for what when it comes to AE. I would like to share a particular question and devote this blog to answering it:
Question: "I’m being questioned about the use of adaptive equipment to facilitate oral access and intake as some believe it relates more to occupational therapy than speech therapy. Can you help me justify?"
"Absolutely, great question!
In general, if OTs and SLPs work in the same facility, the disciplines utilize adaptive dining equipment in different ways and you should document the difference too to avoid duplication of services. It's common practice and workplace etiquette for OTs to focus on accessing the bolus/self-feeding skills and SLPs to focus on oral facilitation/bolus manipulation and a safe swallow during PO intake. SLPs might also focus on self-feeding skills if it is related to cognition targeting initiation and/or sequencing or oral preparatory phase targeting bolus anticipation for improved timing/swallow initiation. OTs who have received training for dysphagia management can do this too.
So, in layman's terms, getting the food to the mouth is generally the OTs part and once the bolus is in the mouth it's the SLPs responsibility. Its very important for OTs and SLPs to collaborate as eating is a dynamic process and the skills of both disciplines are often needed. THE number one risk for aspiration is a patient being fed (Langmore 1998), so the OT and SLP have very important roles for rehabilitating a patient.
Adaptive Equipment Use
Let me provide you with some examples of the differences related to specific pieces of AE.
1. SLPs typically use the Flexi-Cut Cup to facilitate a neutral head position for a safer swallow/improved airway protection (you may also use this cup to squeeze and assist with directing the liquid bolus into the oral cavity). As an SLP you might, and should, consult an OT to see if the patient can physically access the cup re: grasp and general manipulation.
2. Same applies for the maroon spoon. An SLP might choose the maroon spoon to give the patient a smaller bite, as several patients who have a variety of diagnoses such as COPD, CVA, Parkinson's, etc. may need this due to impaired ROM during mastication, to decrease penetration/aspiration to laryngeal vestibule area or if they are impulsive regarding bolus rate and size of presentation. An OT might choose the maroon spoon because it's a light-weight utensil and this may reduce fatigue during PO intake. The OT might also select the maroon spoon for access/grasp reasons as well.
3.Finally, when it comes to the MIT-E spoon, an SLP may select this tool for patients who have trouble with mixed consistencies. An example would be when a patient consumes chicken noodle soup they might experience pre-mature loss of the liquid bolus (broth) resulting in aspiration prior to the swallow. It is normal for everyone to demonstrate mild premature loss of liquid to the level of the hypopharynx when consuming mixed consistencies (Saitoh et. al 2007), however, it is not normal to aspirate frequently (determined via imaging such as FEES or VFSS). Most SLPs would recommend thickening the broth or pureeing the soup altogether. The MIT-E spoon is an option to try to minimize diet restrictions and promote greater patient satisfaction and intake. An OT might use the MIT-E spoon for someone who has upper extremity tremors to help a mixed consistency bolus "sit" better on the bowl of the spoon. This is not its intended purpose, but OTs who have used this spoon report this use.
SLPs should consult OTs if the patient's positioning is having an impact on swallowing as well. For example, sometimes a patient "throws" their head into extension when drinking. This might be related to difficulty rotating the cup and an OT would be most appropriate to consult with regarding solutions/management. I've had patients who pocket food and it's exacerbated d/t a lean and I consult the OT for improved positioning.
Collaboration is, of course, a two-way street. OTs may call on the SLP to assess the impact of AE they've selected to increase self feeding skills on a patient who has dysphagia, such as bendable spoons, cups with a spout and straws.
I wish you the best in using this information in addition to the research and laws that support the use of AE by both OTs and SLPs to justify the necessity of your skills, plan of care and goals; to educate your therapy team. Ultimately I hope your patient benefits from your expertise and newly-gained skill set regarding AE for dysphagia management. You may find our Adaptive Equipment Checklist helpful for staff training, click here to access."
Langmore SE, Trepanning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 1998. Spring; 13(2):69-81. DOI:10.1007/PL00009559
Ney DM, Weiss JM, Kind AJ, Robbins J. Senescent swallowing: impact, strategies, and interventions. Nutr Clin Pract. 2009;24:395–413.
Saitoh et al. (2007). Chewing and food consistency: effects on bolus transport and swallow initiation. Dysphagia, 22(2),100-107.
ASHA Dysphagia Portal Link: http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942550§ion=Treatment#Treatment_Approaches_and_Principles
State Operations Manual Link: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf