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  • 8/22/2019 When is good enough?

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    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.

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    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

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    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