when is good enough?
TRANSCRIPT
-
8/22/2019 When is good enough?
1/3
reflecting most caseloads, but to what extent
does this prepare them to treat dysphagia in head
and neck cancer patients?
In 1999 the RCSLT Education Committee
Dysphagia Working Group published recommen-
dations as to the necessary knowledge base andskills level for pre-registration, post-registration
and advanced level dysphagia education. Figure 1
shows my interpretation of how this applies to
patients with head and neck cancer.
Figure 1 Expected competence
No. of speech Level of Expected competenceand language training (dysphagia associated withtherapists head and neck cancer)
All Pre- Good knowledge of normalregistration anatomy and physiology
of the head and neck,and of the normal swallow.
All of those Post- Knowledge of the needs ofworking with registration clients with complexadults with conditions.
dysphagiaRelatively few Advanced Ability to manage clientsof those post- with complex conditions.working with registrationadults withdysphagia
While there is a wealth of literature on theeffects of surgery and radiotherapy on the swal-lowing process, there is relatively little aboutspeech and language therapy intervention andeven less on the level of expertise or experienceon which that intervention should be based. TheBAO-HNS Consensus Document (2000), for exam-ple, in its chapter on speech and swallowing reha-bilitation talks of team members having suffi-cient post-qualification experience (as well as a
major clinical component in this field). The caseexample in figure 2 (p.5) shows why it is impor-tant that the therapist dealing with people withhead and neck cancer has knowledge of:
1) Staging of tumoursThe first time I encountered the staging classifica-
tion of tumours (BAO-HNS, 2000) in medical
notes, it was a complete mystery. Although the
speech and language therapist is not involved in
the staging progress it is important
to have a clear understanding of the
implications in terms of the likely
surgery and prognosis, and of the
nature of cancer generally.
2) Pre-operative counsellingThe head and neck client group is
unique in that the patient is seen first-
ly with a normal / functional (albeit
diseased) swallowing process, before
the sudden onset of dysphagia
brought about by surgery and / or
radiotherapy and / or chemotherapy.
Doyle (1999) states that pre-operative
counselling provides the single most
important dimension in patient care, therefore
therapists working with this client group need to
ensure they have the necessary skills.
Doyle (1999) talks about using the process of
ollowing the Calman-Hine Reports
standards for patient-centred deliv-
ery of cancer services (1994), we have
seen a shift in organisation and deliv-
ery, including centralisation to cancer
centres or units. This allows patients
to have access to multidisciplinary
teams with knowledge, expertise and experience
in specific cancers. The downside
is that patients may have to travel
considerable distances, especially
where there is a need for ongoing
rehabilitation.
Head and neck cancer patients
often need to attend speech and
language therapy for communica-
tion and swallowing difficulties
resulting from their treatments.
Because of the distances involved,
responsibility is often devolved to
the local community therapist.
All speech and language thera-
pists working with adults with
dysphagia are required to have
post-graduate training. For the majority this is at
a post-registration level, as relatively few go on to
the Advanced level (RCSLT, 1999). It is likely that
their training is largely neurologically based,
competencies
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
F
When does a speech andlanguage therapist havesufficient competency to
manage a client whosedifficulties fall outside theremit of standard training?Lorna Gamberiniexploresthis in relation to peoplewith dysphagia associatedwith head and neckcancer and finds that, as aprofession, we have much
to ponder.
you are interested inhow training andexperience combine toimprove competencyproviding services to alarge geographical areamproving the journeyfrom acute tocommunity services
Read this
When is good
enough?
Post-registrationtraining should
give a therapistthe tools, butthey may needto be applied alittle differentlyto this group thanto neurologicalpatients.
-
8/22/2019 When is good enough?
2/3SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
competencies
Figure 2 Case example
Pre-operativelyMary (64), retired, marriedA social drinker and ex-smoker. Year-long history sore throats (initial tonsil biopsy -no significant abnormality)New investigations found
- poorly differentiated squamous cell carcinoma- a lesion within the left tonsillar fossa, extending anteriorly to the anterior pillar
and floor of mouth, and posteriorly to the posterior tonsillar pillar- Classification: T2 N1 M0Combined clinic (ENT surgeon, maxillo-facial surgeon, oncologist, speech andlanguage therapist, head and neck nurse)Consented to extensive surgery with adjuvant radiotherapyPre-operative counselling with speech and language therapist and head and neck nurse.
Surgeryleft selective neck dissection: level I-IIIresection of tonsillar tumour, involving posterior pharyngeal wall and soft palatemandibulectomyradical forearm free flapskin grafttracheostomy.
Post-operatively (acute)transferred to Intensive Treatment Unit with naso-gastric tube in situ, and cuffed no8Shiley tracheostomy tube.24 hours: ENT ward on intravenous fluids, cuff deflated on tracheostomy tube (speech andlanguage therapist contact for support; communicating effectively by writing and mouthing)2 days: naso-gastric feeds4 days: tracheostomy tube removed by surgeonspeech and language therapy assessment: left sided tongue weakness and loss ofsensation to the left side of tongue, lip and jaw. Trial swallows with fluids triggeredeffectively; no obvious pharyngeal stage problems but some pooling of fluid on theleft. Recommended trial of free fluids, with postural modification to aid transit of bolus.5 days: managing fluids well. Assessed on smooth, semi-solid consistency, somepocketing in the left sulcus, remedied by postural modification. Oral transit slow, but nopharyngeal stage problems. Naso-gastric tube removed; started on liquidised diet.6 days: managing fluids well and tolerating liquidised diet
8 days: discharged home into care of local therapist.Post-operatively (community)Week 2: Coping with free fluids (including fortified drinks) and smooth semi-solids.Complying well with postural modifications.After clearance from the surgeon, range of motion exercises introduced. Reiterated advicere- range of motion exercises, particularly in lessening build up of fibrotictissue and discussed possible deterioration in swallow during radiotherapy.Week 3: Radiotherapy started, continuing with range of motion exercises, oral intakeincreased substantially.Week 4: Tolerating radiotherapy. Some discomfort, but not interfering with oral intake.Continuing exercises - managing without postural modification.Week 5: Struggling with range of motion exercises - very painful. Fluids easiest (relyingheavily on dietary supplements). After discussion with head and neck nurse andoncologist, prescribed Oromorph to help with pain and advised on strategies for coping
with dry mouth (xerostemia).Weeks 6/7: Mary rather disheartened. Very particular about appearance and, althoughoedema and suture lines as a result of the surgery tolerated, added disfigurement fromradiotherapy skin changes is proving difficult.Some difficulty triggering swallow, fibrotic tissue in tongue base. Losing weight as oralintake decreases. Candida and taste changes affecting appetite. Very tired fromradiotherapy. Reassured should see improvement in 2-3 weeks. Dietitian to contact againto advise about food choices.Week 8: Pain and oedema reduced. Candida cleared. Oral intake easier. Coping withxerostemia well. Feels able to start range of motion exercises again - encouraged.Week 10: Less pain. Appetite returning, despite continuing taste changes. Swallowtriggering faster. Does not need postural modification. Mary trialling new textures herselfand feeling much more optimistic about returning to pre-operative diet.Four months post-operatively: Good progress. Range of motion exercises regularly, rapidlyputting weight back on. Able to eat most foods, even if modified form. Xerostemia and
taste changes persist.
pre-operative counselling for the therapist and
patient to set common goals for rehabilitation.
Logemann (1983) discusses the difficulty of initiating
therapy post-operatively with a patient who has
been unprepared for the problems of swallowing.
Although consent for surgery or radiotherapy isobtained primarily by medical and surgical members
of the team, the speech and language therapist has
an important role in ensuring that the patient is
fully aware of the consequences for speech and
swallowing.
3) Tracheostomy tubes and their effect onswallowingKnowledge of the needs of clients with tra-
cheostomy is included in the Dysphagia Working
Groups recommendations for inclusion in post-
registration courses. Any patient who presents
with a compromised airway because of a head
and neck tumour may require a tracheostomy
(Ridley, 1999) Additionally, a tracheostomy may
be performed as a temporary measure until soft
tissue swelling has resolved post-operatively.
4) Swallowing assessmentSkill in selection and interpretation of swallowing
assessment procedures such as videofluoroscopy
and FEES (Fiberoptic Endoscopic Evaluation of
Swallowing) covers all client groups (RCSLT,
1999b). Here, however, to interpret the results of
any assessment accurately, the therapist must
have a very good understanding of the nature of
cancer, of the structural changes that have taken
place after surgery and of the effects of any con-
comitant treatment (Ridley, 1999).
5) Management of swallowing problemsAbility to use appropriate compensatory tech-
niques, exercises, positioning and change in consis-
tencies is a desired outcome of post-registration
training. Sullivan (1999) states that, for people with
head and neck cancer, therapy goals typically focus
on compensation rather than long-term improve-
ment of swallowing function. Post-registration
training should give a therapist the tools, but they
may need to be applied a little differently to this
group than to neurological patients.
6) Multidisciplinary team workingPost-registration courses aim to give speech and
language therapists knowledge of multidisciplinary
team working. The therapist is very much a core
member of the team providing an integrated service
to people with head and neck cancer, and has an
important role in raising awareness of swallowing
problems with the other team members.
7) Radiotherapy and its effectsAny therapist working with this client group needs to
be aware of potential treatment induced swallowing
problems, and prevention and therapy strategies.
The speech and language therapist has the best
knowledge of a patients swallowing status post-
operatively. She can therefore advise the team
-
8/22/2019 When is good enough?
3/3
AcknowledgementWith thanks to Linda Slack, Macmillan speech and
language therapist for North Cumbria who
looked after Mary at the acute stage.
ReferencesBritish Association of Otolaryngologists - Head
and Neck Surgeons (2000) Effective Head and
Neck Management - Second Consensus
Document.
Burgess, L. (1994) Facing the reality of head and
neck cancer. Nursing Standard8 (23): 30-34.
Calman, K. & Hine, D. (1995) A Policy Framework
for Commissioning Cancer Services. London:
Department of Health.
Doyle, P. (1999) Postlaryngectomy speech rehabil-
itation: contemporary considerations in clinical
care.Journal of Speech-Language Pathology and
Audiology23 (3): 109-115.
Harris, C. (2001) Ahead and neck of the field.Speech & Language Therapy in Practice. Autumn:
12-13.
Logemann, J. (1983) Evaluation and Treatment of
Swallowing Disorders. Pro-ed, Austin, Texas.
Ridley, M. (1999) Effects of surgery for head and
neck cancer. In Sullivan, P. & Guildford, A. (Eds)
Swallowing Intervention in Oncology. Singular
Publishing Group: San Diego/London.
Robinson, H.F. (1999) How I manage head and
neck cancer: Setting the standard. Speech &
Language Therapy in Practice. Autumn: 23-24.
Royal College of Speech & Language Therapists
(1996) Communicating Quality 2. RCSLT: London.
Royal College of Speech & Language Therapists
(1999a) Dysphagia Working Group:
Recommendations for Pre and Post-registration
Education and Training. RCSLT: London.
Royal College of Speech & Language Therapists
(1999b) Invasive Procedures Guidelines. RCSLT:
London.
Sullivan, P. (1999) Clinical Dysphagia Intervention.
In Sullivan, P. & Guildford, A. (Eds) Swallowing
Intervention in Oncology. Singular Publishing
Group: San Diego/London.
Williamson, K. (2000) The best things for the best
reasons. Bulletin of the Royal College of Speech &
Language Therapists. October.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
competencies
before the onset of radiotherapy or
chemotherapy as to any need for non-oral
nutrition once the treatment effects are
added to the effects of surgery. It is unlikely
that this specialised and highly important
knowledge would be included in generaltraining.
8) Body imageBoth head and neck cancer and the treat-
ments for it can affect an individuals
appearance. Burgess (1994) includes not only phys-
ical change but also change in bodily function or
control of the bodys activities, and the speech and
language therapist needs to have an awareness of
the possible psychological implications.
Writing about the background to the RCSLT
Competencies Project, Williamson (2000) states
that: Although some skills and knowledge are
core to speech and language therapy profession-
alism, their profile and depth will vary according
to particular clients demands, contexts and ther-
apists responsibilities. On its own, attendance at
a dysphagia course does not make a therapist
competent. A therapist who has attended a post-
registration course, and has much clinical experi-
ence, can easily be as competent to treat dyspha-
gia in a head and neck patient as someone like me
who attended an Advanced course, but had rela-
tively little clinical experience. Experience may
come about by direct patient contact, or simply
from working with the multidisciplinary team. In
attending the Combined Clinic each week, I
learned a significant amount about the wholespectrum of head and neck care - prevention,
recurrence, palliative care, carotid blow out for
example - all of which informed my practice.
Communicating Quality 2 (RCSLT, 1996) states that
therapists working with this client group tend to
learn by experience.
In outlining the content of dysphagia courses,
the Dysphagia Working Group makes it clear that,
while a therapist completing the course would be
expected to be able to work without supervision,
the ability to know when to ask for support
would mean the therapist is working competent-
ly. What may be problematic is ensuring that that
support is available.
The literature suggests that speech and lan-
guage therapy intervention for this client group is
optimally delivered by therapists with specific
responsibilities for head and neck cancer (RCSLT,
1996; Ridley, 1999; BAO-HNS, 2000), who will be
part of multidisciplinary teams working in cancer
centres. If the therapist linked to a particular centre
has the ability to be peripatetic, this may not be a
problem. However, if geographical or time con-
straints prevent this, there is a dilemma as to
whether the patient will travel for rehabilitation, or
be seen by the local speech and language therapist.
Would a local therapist, without specialist training
or specific clinical experience be appropriately
qualified, and would they be able to deliver high
quality, safe and effective treat-
ment (Calman & Hine, 1994)? I
believe the answer is possi-
bly. I cannot be more positive
due to uncertainty over the
amount of support the thera-pist would receive. Issues of
competence and asking for sup-
port do not take account of fac-
tors such as Trust boundaries,
geography and politics, which
can hamper communication between therapists
and the contact that is needed to provide appro-
priate support. Harris (2001) describes a clinical
liaison group set up to improve communication
between professionals, vital when patients are
travelling across Trusts.
At the acute stage, there should be support from
the other members of the multidisciplinary team,
whereas a community therapist may be working in
isolation, and dealing with the head and neck can-
cer patient at what is often the most traumatic
time. Discharge home can bring about a stark reali-
sation of problems they have to overcome. The
swallowing problem may take on more significance
when the choice is no longer from a hospital menu
and the social aspect of eating comes to the fore,
and all this at a time when further treatment may
start and worsen the dysphagia.
General dysphagia training gives therapists a
good basic grounding in managing dysphagia in
head and neck cancer patients. If there are very
good support systems in place, it is possible that a
generally trained therapist could successfully
manage the dysphagia. However, there are stillaspects of care, such as pre-operative counselling,
that are so important to the outcome of the reha-
bilitation that they should remain within the
remit of a therapist with specific responsibilities
to this client group.
Robinson (1999) reports on the drawing up of the
Head and Neck Oncology Consensus document,
and the fact that some of the objectives were
unachievable in certain areas because of issues such
as geography. Despite this, they were included
because, ultimately, they were good practice, and
could be used to help highlight deficiencies in local
service provision. This process needs to continue to
ensure parity of service for head and neck cancer
patients, no matter where they live.
I am not sure if it is possible to quantify the level
of expertise and training required to work with this
client group, but it is an area that the profession
needs to explore. For the sake of career progression,
continuing professional development and ultimate-
ly patient care, it would be helpful to have some
way of gauging when ones experience is sufficient.
Lorna Gamberini is a speech and language thera-
pist who works with ENT clients for Morecambe
Bay Primary Care Trust. This article is based on the
essay component of the Advanced Dysphagia
Course (Head & Neck Module) which was written
while Lorna worked for West Cumbria Primary
Care Trust.
Issues ofcompetenceand asking forsupport do nottake accountof factors such
as Trustboundaries,geographyand politics
Do I recognise when to ask forsupport and do I know whereto get it?
Do I see myself as anindividual or part of a networkof service provision?
Do I expand my knowledgethrough involvement inmultidisciplinary ventures?
Reflections