Speech pathologists and rehabilitation services.

Speech-language pathologists (speech pathologists) are important members of rehabilitation teams. As indicated in the Scope of Practice of the American Speech-Language-Hearing Association (ASHA) (1990 a), their chief responsibilities are to:

* identify, assess, and provide treatment for individuals of all ages with communication dosorders;

* manage and supervise programs and services related to human communication and its disorders;

* counsel individuals with disorders of communication, their families, caregivers, and other service providers relative to the disability present and its management; and

* provide consultation and make referrals.

Facilitating the development and maintenance of human communication is the common goal of speech-language pathologists and audiologists.

The speech pathologist committed to the rehabilitation setting works with a variety of patients, including persons recovering from stroke or traumatic brain injury, those with a history of cancer of the throat or mouth, and individuals with congenital cerebral palsy. The speech pathologist may provide diagnostic and treatment services to patients with degenerative neuromuscular diseases, such as multiple sclerosis or Parkinson's disease. In fact, it is common for the work of the speech pathologist to complement and advance the efforts of the rehabilitation counselor.

The responsibilities of the speech pathologist involve a diverse range of skills and competencies. In addition, these activities are conducted across all work settings that provide rehabilitation. Services are frequently initiated in the acute care medical setting, often continue in specialized rehabilitation units or outpatient departments, and may proceed through varying forms of long-term care, home health, or other forms of extended service.

Speech pathologists working in these settings are members of interdisciplinary teams charged with direct patient management. As a team member, the speech pathologist is the authority on communication function. Primary responsibilities include contributing to decisions regarding the patient's most effective mode of communication and the subsequent provision of treatment to optimize communication and related abilities. Services of speech pathologists are recognized as essential in total patient management. For example, the Joint Commission on Accreditation of Hospitals (JCOAH) requires that speech pathology services must be provided before a facility can maintain its designation as a provider of comprehensive rehabilitation.

Treatment services focus on functional outcomes and are often organized to address activities of daily living (ADL's), even though traditionally accepted listings of ADL's exclude communication competence. Activities in this regard include patient instruction designed to maximize comprehension and expression of needs with attendant physicians, nursing care staff, other healthcare practitioners (e.g., physical and occupational therapists), and family members. Speech pathologists make determinations about the frequency and intensity of these intervention strategies based on numerous factors, including such issues as medical stability of the patient, presenting etiology, and potential for improvement. Decisions are typically made in concert with input from the managing physicians.

Specific responsibilities include assessment and management of disorders of speech and language, dysphagia (disorders of swallowing), identification and treatment of persons requiring augmentative or alternate forms of communication, the assessment and treatment of cognitive/communication disorders, the provision of aural rehabilitation services to hearing impaired individuals, and facilitating communication effectiveness, as with persons requiring foreign accent reduction.

It is interesting to note that many rehabilitation clients have speech, language, swallowing, and cognitive disorders that are secondary to their primary diagnoses. For example, cerebral palsied and traumatically brain-injured persons may have need for augmentative communication devices. Laryngectomy patients require alternative, prosthetic vibratory sources for speech production or they may benefit from secondary surgeries followed by speech therapy. Persons who have had cancer of the mouth and whose tongues have been removed (glossectomee) need intensive speech therapy. Patients recovering from storke often need specialized assistance with swallowing to ensure safety in maintaining oral nutrition.

Dysphagia treatment is representative of specialized skills and knowledges in contemporary medical speech pathology. It is important to understand the need to diagnose and treat swallowing disorders, since unrecognized dysphagia may lead to multiple health problems, such as potential for repeated aspiration pneumonia, a condition that may be life threatening, and poor nutritional and hydration status. Also, persons with dysphagia may endure social penalties if they cannot bite, chew, and swallow food and drink liquids without coughing and choking. The speech pathologist plays a significant role in determining if oral exercises, dietary changes, feeding assistance, or changes in technique will help the patient to maintain a more normal pattern of oral intake.

According to Miller and Groher (1990), "Some patients with neurologic disease evidence disorders of deglutition (swallowing) secondary to impairment of the oropharyngeal muscle complex and, in some caes, to involvement of both the striated and smooth muscle of the esophagus. Evaluation and treatment of these disorders are important to the patient's medical evaluations, and referrals to the speech-language pathologist are appropriate. The evaluation and remediation of disorders of deglutition involve a new, but recognized, role in the field of speech-language pathology. Most physicians are not aware of the fact that consulting with the speech-language pathologist for evaluation of a dysphagic patient could be useful. In the past, most consultations were with the otolaryngology and gastroenterology services. Cooperation among all four services (speech-language pathology, otolaryngology, gastroenterology, and neurology) often is needed for optimum management of the dysphagic patient" (p.37).

In addition, departments of radiology play an integral role in this multidisciplinary arena. Speech pathologists and radiologists have developed procedures for modified barium swallow approaches, including positional and postural adjustments and various liquid and solid mediums, for optimal diagnostic value. These procedures allow the speech pathologist and radiologist to evaluate structures and functions of the mouth, the throat (pharynx), the voice box (larynx), and the passageway from the throat to the stomach (esophagus). Clinical and technological efforts focusing on dysphagia have led to many advances, from the development of specialized diagnostic equipment to an impressive and growing body of disciplinary scholarship.

In these and in many other instances, the speech pathologist is a valuable member of the outpatient rehabilitation care environments, speech pathologists provide supportive information for early medical presentations through the identification of behavioral change associated with neurological lesions. These contributions provide the impetus and direction for early initiation of treatment. Services are often housed in departments of physical medicine.

There are other essential skills and knowledge the medical speech pathologist employs in acute care settings that transcend expertise with specific types of disorders. These include understanding of pharmacology and nutritional support, competence in cognitive and behavioral management, and knowledge of both informational and personal adjustment counseling.

Patients discharged from acute care or inpatient rehabilitation settings may continue to receive treatment as clients of outpatient departments, as residents of nursing care facilities or through home health services. Speech pathologists treating outpatients are challenged with the transfer and maintenance of skills fostered in the more intensive inpatient circumstances to home or other long-term care environments. This process frequently involves eduction and monitoring of support systems for individual patients. At the same time, it is acknowledged that discharge from the acute or long-term care facility reflects positive progression.

In outpatient settings speech pathologists continue as members of rehabilitation teams. Their perspectives on patient communicative function and needs are frequently an important piece of the profile of recovery and their interaction with other disciplines is crucial in the broad range of recovery activities.

Placement in a nursing care facility is one option for patients who require specific medical care. Since guidelines of the Council on Accreditation of Rehabilitation Facilities (CARF) require that these settings have access to appropriate rehabilitation services, including speech-language pathology services, speech pathologists in nursing care facilities are frequently involved in direct treatment of the patient as well as adapting the environment and familiarizing the nursing care staff with the specific needs of individual patients over time. It should be noted that rehabilitation in a long-term care facility does not imply long-term treatment. As previously indicated, functional outcome measures provide a basis for determination of necessity of service and success of treatment in these facilities.

Home healthcare is another option in the recovery process. Since caretakers in the home are most often family members--those with whom interaction may be most important--service provision in these settings presents the clinician with access to an environment familiar to the patient. As a result, efforts to foster optimum communication is frequently less contrived under these conditions. Specific treatments to facilitate speech can be integrated into activities of daily living and the speech pathologist is afforded a natural setting for counseling patients and their families.

Some speech pathologists address the communication needs of persons who have dementia, a situation which provides opportunities for a better understanding of the relationship between brain behavior and cognitive and communicative functioning (Lubinski et al., 1991). Clinicians working with patients with dementia must idetify the communicative characteristics which help to differentiate the dementias and to develop rigorous intervention strategies to make use of the patient's residual communication skills. Additionally, speech pathologists in acute care and rehabilitation settings are often asked to assist in distinguishing those behaviors which may be secondary to stroke, or other neural insult, from those which may be related to one of the dementias.

In addition to responsibilities as team members in direct patient management, speech pathologists contribute to healthcare teams through inservice education activities. It is important for other team members, independent of work setting and implementation models, to understand the range of responsibilities and associated competencies of speech pathologists.

Some individuals retain, or can develop, language competence even though they may have been rendered unable to speak as a result of congenital, developmental, or traumatic events. These may include persons with severe cerebral palsy, degenerative diseases such as amyotrophic lateral sclerosis (ALS; "Lou Gehrig's Disease"), closed-head injuries, and patients who are ventilator dependent. To assist in facilitating extensive and productive communication among these patients, speech pathologists have access to a vast array of technological devices, ranging from simple, non-electric picture communication boards to complex and sophisticated computer-based systems.

The emergence of this technology since the early 1970's has resulted in an international network of agencies, special interest groups, and individuals specializing in augmentative communication. Speech pathologists have been the driving force of this movement.

In addition to issues of assisted methods of communication, individual patients might require consideration of alternative modes of communication. This might incorporate a nontraditional language system. One example of this is sign language as used by members of the deaf community. Another example familiar to speech pathologists would be the alternative symbol systems which might be employed to facilitate the essential functions of language (i.e., to effect environmental change and exchange thoughts and emotions). Valuable resources in this area are the International Society for Augmentative and Alternative Communication (ISAAC) and the AAC journal, Augmentative and Alternative Communication.

Another area requiring the expertise of speech pathologists with the assistance of specialized technology is in treatment and services for individuals who have had surgery to remove their larynx, usually because of laryngeal cancer. Today, laryngectomized persons have several options for regaining expressive function. These include the development of esophageal speech, the use of a variety of electrolarynges (prosthetic, external vibratory sources), and/or speech with the aid of a prosthetic valve to more closely approximate original voice quality. The speech pathologist works closely with the otolaryngologist and other team members in implementing successful laryngectomee rehabilitation.

Other aspects of clinical speech pathology also benefit from the use of advanced technology. Computer applications are abundant, with software continuously being developed for assessment and treatment. The refinement of speech synthesis capabilities allow programs to "talk" to and for the patient. Therapeutic activities for cognitive retraining have been positively impacted by the developments in computer applications. Individuals requiring practice in problem solving, vocabulary enhancement, sequential memory skills, and other cognitive/language domains are likely beneficiaries of computer applications in speech pathology.

Solutions to problems of access to high tech devices have been both creative and plentiful. Switching devices are available that can respond to subtle cues ranging from simple muscle activity to eye movement. These advances have also led to greater independence for people with severe disabilities by expanding their ability to effect environmental control. Future computer applications in areas such as artificial intelligence hold additional promise for communication enhancement, conceptual retraining, and similar skill development among language impaired patients.

Practitioners in speech pathology will continue to be involved in efforts to assure quality of care and in assisting the development of effective and efficient healthcare. The American Speech-Language-Hearing Association has developed a number of position statements, reports, and guidelines regarding aspects of service delivery in rehabilitation (ASHA; 1989; 1990 a, b, c; 1991 a, b). The recently published Preferred Practice Patterns for the Professions (ASHA, 1993) provides detailed information on speech pathology concerning clinical indications for procedures, clinical processes, setting and equipment specifications, safety and health specifications, and documentation guidelines for use by professional peers, third-party payers, administrators, and the general public.

ASHA also maintains a professional practices office to assist members with matters concerning quality care. Activities conducted with other national organizations have also resulted in positive collaborative outcomes. One example is the Functional Independence Measure (1990), a means for documenting the outcomes of medical rehabilitation. The instrument's development involved efforts of the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Efforts within the discipline and in conjunction with other healthcare providers will continue to insure the growth and refinement of clinical practices.

In summary, speech pathologists perform a critical function in the rehabilitation process. Their responsibility for facilitating optimum communication function occurs in a variety of work settings, with persons representing diverse etiologies. Advances in the skill and knowledge base within the discipline and in interdisciplinary technology have provided speech pathologists an armamentarium with which to address the challenges of patients who are communicatively disabled. Speech pathologists are prepared to work with patients in a variety of settings to assist in the development of the precious human capability to communicate.

Bibliography

1. American Speech-Language-Hearing Association (1989). Competencies for speech-language pathologists providing services in augmentative communication. ASHA, March, 107-110.

2. American Speech-Language-Hearing Association (1990a). Scope of Practice, Speech-Language Pathology and Audiology, ASHA, 32 (Suppl. 2), 1-2.

3. American Speech-Language-Hearing Association (1990b). Major issues affecting the delivery of services in hospital settings, ASHA, April, 67-70.

4. American Speech-Language-Hearing Association (1990c). Skills needed by speech-language pathologists providing services to dysphagic patients/clients, ASHA, 32 (Suppl. 2), 7-12.

5. American Speech-Language-Hearing Association (1991a). Guidelines for speech-language pathologists serving persons with language, socio-communicative, and/or cognitive-communicative impairments. ASHA, 33, (Suppl. 5), 21-28.

6. American Speech-Language-Hearing Association (1991b). Guidelines for the delivery of speech pathology and audiology services in home care. ASHA, 33 (Suppl. 5), 29-34.

7. American Speech-Language-Hearing Association (1993). Preferred Practice Patterns for the Professions of Speech-Language Pathology and Audiology (Suppl. 11).

8. Lubinski, R., Orange, J.B., Henderson, D., Stecker, N. (Eds.) (1991). Dementia and Communication. Philadelphia: B.C. Decker, Inc.

9. Miller, R.M., and Groher, M.E. (1990). Medical Speech Pathology. Rockville, Md: Aspen Publishing Co.

10. Research Foundation--State University of New York, (1990). Guide to the Uniform Data Set. Buffalo: State University of New York, School of Medicine, Department of Rehabilitation Medicine.