Speech and language therapist – 1
What is the unique contribution of a speech and language therapist to the rehabilitation team’s collective expertise? I persuaded a brave colleague to write this post. Harriet Peel was the speech and language therapist in the rehabilitation team at the Dean Neurological Centre, a care home where I work. The content after the Table of Contents is entirely hers. My only editing was to correct any spelling or grammar and to lay out the text. She aimed to inspire people to become speech and language therapists. I aim to foster discussion on the strengths of each profession. In a team, much knowledge and many skills are shared. This gives the team resilience and the ability to function without a team member but, functioning satisfactorily for a short time does not prove that the expertise is unnecessary. Indeed, it is evidence that the missing person has contributed to the team’s expertise. If you are a speech and language therapist, you might like to comment on this post at the bottom. Better still, you might like to write a post with your views.
This post was first published on 12 March 2022. This version has a new introduction and a different layout, but its content is the same.
Table of Contents
My name is Harriet Peel, and I currently work as a “Highly Specialised Speech and Language Therapist”. I work in a neuro-rehabilitation centre with very complex patients who are likely to have a range of clinical problems, ranging from mechanical ventilation and tracheostomies to prolonged disorders of consciousness and severe global impairments, with less severely affected patients on their way home in the middle.
In this blog post, I hope to share some insight into how vast the role of a Speech Therapist can be. I have tried to divide the role into:
- ‘Direct’ – explaining the role within clinical interventions
- ‘Indirect’ – explaining the role within an organisation
Speech and language therapist: direct interventions.
Typically, direct therapy by a speech and language therapist within a rehabilitation team usually takes one of three formats:
- To rehabilitate a person’s swallow
- To rehabilitate a person’s communication ability
- To rehabilitate a person’s respiratory status: which will usually encompass the rehabilitation of points 1 and 2.
To look into these in a little more detail:
The 12 cranial nerves are located within the brain and nine of these cranial nerves are required to swallow safely and effectively. Swallowing “safely” assumes no aspiration of food or fluid onto the lungs and a very low risk of choking. Therefore, it is reasonable to assume that following a neurological event there is likely to be some impairment to the swallow function.
The assessment of a “safe” swallow falls into the remit of a speech and language therapist. It is important to note that in four years of training, the education on dysphagia is covered in just one module. To be a dysphagia “competent” therapist, you must undertake post-graduate study.
Starting a swallowing assessment involves an element of risk, and I am passionate about the idea that you must undertake some element of risk in order to rehabilitate. I believe that the role of a therapist is to try to identify the level of risk and to support people in making a decision about what level of risk they are willing to take.
Once a baseline swallow has been identified, a rehabilitation programme can be developed to provide exercises that target sensory and motor innervation. Another belief I hold is that there is no better rehabilitation than actually eating something you enjoy.
Whilst the speech therapist will hold a lot of expertise linked to the swallow, there will still be a reliance on many other professions to support diagnosis for example:
- Ear, Nose and Throat (ENT) Consultants to jointly complete fibreoptic endoscopic evaluation of swallowing (FEES) assessments
- Respiratory physiotherapists to complete chest examinations
- Dieticians to support the discussions in enteral feeding
- General Practitioners (family doctors) and/or specialist doctors, to give a holistic oversight into their condition or advise on medication.
The role often also involves education, counselling and supporting complex decision making. Some of the complex topics may include:
- To remove enteral feeding due to a successfully rehabilitated swallow
- To insert a gastrostomy tube due to an unsafe swallow
- To withdraw from enteral feeding, making the choice to decline life-sustaining intervention.
Take a moment to consider how it might feel if you woke up tomorrow and you were unable to talk. Hopefully, this thought will provide some context into the role of speech therapy within neuro-rehabilitation. The communication chain is complex and rehabilitation can span from establishing a consistent yes/no to using an eye-gaze device (think Steven Hawking and you won’t be too far off the mark). This thought assumes that there is no cognitive impairment.
Alternative Augmentative Communication devices (AAC) e.g. an eye-gaze device is a specialist skill in itself. It requires a broad range of knowledge of the devices that exist and as technology grows the goalposts are ever-changing.
Communication in a healthcare setting is particularly important as it directly links to a patient’s ability to consent to their treatment and rehabilitation. The first question of the mental capacity act is: “Is the person able to communicate their decision effectively?”. I believe that the role of a speech therapist is vital in making sure that each individual has the opportunity and means to communicate if they are able to.
Respiratory rehabilitation is highly individualised and complex, so for the purpose of this blog post I will try to give a brief summary. In my opinion, it is highly important to note that none of the below would be possible without the multi-professional team. The role comprises of:
- Swallowing assessment particularly identifying aspiration events
- Swallowing rehabilitation
- Tracheostomy weaning
- Voicing and the use of a speaking valve
- Supporting the management of secretion load
Speech and language therapist: indirect interventions.
This part considers the question, “What is the role of a speech and language therapist within an organisation?”
This bit becomes a bit more difficult to pinpoint as it may differ from organisation to organisation however to name a few:
- Writing policies such as a dysphagia policy
- Supporting decision making around risk management
- Providing education/training for healthcare staff
- Creating links with other localities and understanding services that are available
- Onward referrals to appropriate specialist
- Mapping and identifying appropriate community services to manage complex needs upon discharge home
When I began my training, and indeed when I finished my training, I think I was quite naïve in understanding the vast role that a Speech and Language Therapist has to play in Neurological Rehabilitation. Hopefully, I have managed to share some insight.
To finalise this blog I thought it might be useful to share some clinical examples to put things into perspective:
- Recently I was working with a gentleman who had not eaten or drank for 3 years, we worked together for several months and he has since regained ability to eat and drink a normal diet. This gentleman hadn’t eaten a meal with his son for many years and now is able to go to the pub to watch the sport and have a pint like father and son.
- Another gentleman has had a long term tracheostomy tube, which has left him without a voice for 4 years. We worked together for many months and he is now able to speak the names of all his children out loud. It was an emotional moment, as he was able to say hello to each of his children after such a long time.