We are pleased to welcome Cathy Lazarus, Ph.D, from Northwestern
University, in our SLP student chat tonight,  October 22, 2001. 
Dr. Lazarus's primary interest includes speech and swallowing disorders
in surgically treated head and neck cancer patients.  Her clinical
work involves assessing speech and swallowing disorders,
using bedside and clinic tests as well as videofluoroscopic
examinations of swallowing, and providing therapy to improve both
skills. Dr. Lazarus also works with neurologically based communication
disorders and dysphagia in an acute care hospital setting.
Outpatient clinic interests focus on assessment and treatment of
functional voice disorders.  Dr. Lazarus will be making three presentations
at the upcoming ASHA convention, "Difficult Cases in Dysphagia Management",
"Functional Recovery of Swallowing Following Brainstem Tumor Removal:Case
Study", and "Effects of Liquid Wash on Swallowing in Cancer Patients".

<Robin> Welcome!  Tonight we are chatting with Dr. Cathy Lazarus from Northwestern
    University about Swallowing Disorders
<Robin> We're glad everyone could join us tonight
<cathy lazarus> so does anyone have any juicy questions about swallowing, no pun
<Cathy Lazarus> Are folks on board grad students, or practicing clinicians?
<Adrienne FSU> I'm a grad student, I have a regular client, plus I'm on a diagnositc
<Adrienne FSU> but haven't had a swallowing class yet
<Adrienne FSU> Dr. Julie Steirwalt just came to FSU, I will take her class next year
<Cathy Lazarus> Glad you are at least offered one!
<Anonymous2848> undergrad student from Eastern Washington University
<Cathy Lazarus> Does Eastern Washington U. offer a class in swallowing?
<Anonymous2848> I'm actually not sure if the grad program offers a course in
    swallowing at EWU
<Robin> Dr. Lazarus, do most SLP grad programs offer a class in swallowing
<Cathy Lazarus> Actually, most programs do NOT offer a class, unfortunately, since
    ASHA is now finally seeing swallowing as an important part of the graduate program
<Cathy Lazarus> I don't think there are more than a handful that offer a full course. Some
    programs offer a few lectures, unfortunately.
<Cathy Lazarus> Hopefully, you will be able to work with dysphagic patients in your off
    campus practicums.
<Anonymous144> I am a grad student at Boston University
<Cathy Lazarus> I think BU offers a course in swallowing.
<RRS- BU> Yes, at BU we have both a required course in dysphasia (only 2 credits)
<Cathy Lazarus> There are tons of great hospitals in the Boston area to do your
    swallowing practicum.
<RRS- BU> we also have an elective course at BU...but both focus on adults
<Cathy Lazarus> You'll likely only get a lecture or two on peds, even in a full course.
<Robin> Kathy, do you have a swallowing disorders course at CSUN?
<kathy> we had a mini lecture on swallowing during my first 2 months of grad school. I
    will take a neurogenic disorders of swallowing class in the spring
<kathy> thats the extent of it
<Robin> Does anyone have any specific questions for Dr. Lazarus?
<Robin> Dr. L, can you give the students a general idea of how common swallowing
    disorders are in the adult population?
<Adrienne FSU> yes, and I was wondering if it's much less in the peds?
<Cathy Lazarus> yes, it's pretty common in stroke - about 30% have problems afterward.
    Also quite common in head and neck cancer, TBI, spinal cord injury. Much less so in
    peds, tho more in preemies.
<Cathy Lazarus> I just got back from the annual Dysphagia Research Society meeting
    in Albuquerque. I highly suggest you attend once you are out of school and can afford
<Robin> what is the latest research?
<Cathy Lazarus> Was alot on the esophagus, actually - especially lower sphincter - not
    very interesting. But were also good scientific papers on normal swallowing,
    breathing/swallowing, normal volumes of sips, etc.
<Cathy Lazarus> also some good posters, which are much less stressful for the
<Adrienne FSU> is the sucking ability considered part of swallowing disorders?- for
<Cathy lazarus> Yes, it definitely is. Can be related to reduced tongue strength or just
    poor coordination of suck and breathing.
<Cathy Lazarus> Can also be related to reduced lip strength.
<Adrienne FSU> what sorts of things can you do to help that?
<Cathy Lazarus> That's a tough one. You really try to stimulate the baby to suck and try to
    get more muscle activity. Lots is just hands on working around and in the mouth.
<RRS- BU> I feel fairly comfortable doing a dx via videoflouroscopy, but what is a good
    protocol for a bedside differential dx ?
<Cathy Lazarus> That's a great question, RRS-BU! There's not a great deal of
    agreement on the clinical evaluation and how useful it is compared to the VFG x-ray
<Adrienne FSU> ok
<Cathy Lazarus> The bedside does give you good info on muscle function for speech,
    cognitive status, alertness, etc., But doesn't tell you alot about the swallow itself,
    especially if the person is aspirating silenty
<Robin> what is the protocol in most facilities?
<Cathy Lazarus> usually, the clinician gives SMALL volumes of liquids and perhaps
    pureed consistencies, gets a gross feel for oral and pharyngeal transit time and a
    gross feel for laryngeal elevation during the swallow
<Cathy Lazarus> Get some feel for aspiration, if the person is coughing, has wet, gurgly
    voice, etc.
<Cathy Lazarus> However, you don't get a good feel for what the pharyngeal phase
    disorders are.
<Robin> exactly
<Adrienne FSU> what about using a stethescope?
<Cathy Lazarus> There are NO data to date correlating cervical ascultation (or sound of
    swallow) with anything physiologically. Meaning - you can't tell by the sound what's
    going wrong.
<Adrienne FSU> but can you tell that it doesn't sound right?
<Cathy Lazarus> There are folks who swear they can tell a normal from an abnormal
    swallow, which may be true. But that doesn't help you know what to do, if you don't
    know what's physiologically wrong with the swallow
<Adrienne FSU> makes sense
<RRS- BU> So in a situation like you were discussing, doing a bedside eval, how
    comfortable can you be making a dx/decision to modify or not modify a diet?
<Cathy Lazarus> RRS-BU - great question - not comfortable at all! Unless the swallow
    looks really good and the person isn't very dysarthric, or not dysarthric at all.
<RRS- BU> right...in reality, I am really fascinated by the anatomy/physiology aspect of
    swallowing disorders, but feel VERY nervous (at this juncture, anyway) in situations
<Robin> Dr. L, will most MDs write an order for a video ?
<Cathy Lazarus> yes, Robin, most docs will order a VFG, thank goodness.
<Cathy Lazarus> Adrienne - hopefully, you'll have a good mentor/CFY supervisor who
    will guide you well.
<RRS- BU> Can we talk therapy for a bit?  My course and clinical experience (peds)
    were very diagnostic-focused.  not much talk about tx strategies other than diet
<Cathy Lazarus> Back to bedside evals, there are alot of people who are trying to get
    good bedsides, but none are perfect.
<RRS- BU> Are there any tried and true tx strategies that you give a lot?
<Cathy Lazarus> Indeed! Postures and maneuvers and the combinations give you alot
    of bang for your buck and there's plenty of research to back them up.
<Robin> how true!
<Cathy Lazarus> No one should pass on trying postures and maneuvers, unless the
    person cannot cognitively perform them in x-ray. Then, diet modifications are the next
<Adrienne FSU> do you ever recommend both?
Adrienne FSU> posture and diet?
<Robin> Dr. L, can you elaborate on some of the common postures and manuevers
<Cathy Lazarus> Sure. The common postures used include chin tuck, useful for
    swallow delays or reduced airway closure. head back for facilitating oral transit, head
    rotation for a unilateral glottic paralysis or pharyngeal weakness.
<Adrienne FSU> what is oral transit?
<Cathy Lazarus> oral transit is getting the bolus of food or liquid from the mouth to the
<Cathy Lazarus>  Maneuvers include super supraglottic swallow
    to improve airway closure, mendelsohn to imrpove laryngeal motion and UES
    opening, effortful swallow to improve tongue base motion.
<Cathy Lazarus> Postures are designed to change the flow of the bolus and maneuvers
    change the swallow itself.
<Adrienne FSU> makes sense again
<Cathy Lazarus> Oral transit takes a second or less.
<Adrienne FSU> what about when dentures affect oral transit?
<Cathy Lazarus> No, dentures don't affect oral transit, unless they don't fit!
<Cathy Lazarus> You'd be surprised how many folks who are edentulous (no teeth) eat a
    normal diet.
<Adrienne FSU> that's what I mean...
<Cathy Lazarus> If they don't fit, they're better off not wearing them.
<Adrienne FSU> ok
<Cathy Lazarus> Some folks have to always use postures and/or maneuvers when they
<cathy lazarus> Even if some of you ending up working in the schools, you'll probably
    see some kids with swallowing problems, since alot are being mainstreamed.
<Anonymous464> so do you get a wide variety of ages...I mean of your patients how
    many are of the elder generation?
<cathy lazarus> The majority of my patients are over 30, with the bulk over 60. We don't
    see too many peds and kids, but we're an adult hospital. Just see a few kids on an
    outpaitent basis.
<RRS- BU> would you contrast the super supraglottic and effortful swallows?
<cathy lazarus> Yes, the super supraglottic swallow is an airway closure technique,
    where the person holds his breath. Effortful is a "Hard" swallow, to improve tongue
    base posterior motion.
<kathy> dr L, you said mendelsohn improves laryngeal motion. can you explain how it
    does that? i dont get it.
<cathy lazarus> Yes, you ask the person to swallow and hold their larynx up - it
    prolongs and increases laryngeal motion and also keeps the UES open longer and
<Adrienne FSU> wow, that feels hard even for me to do
<cathy lazarus> Effortful swallow and super supraglottic are easy, but, yes, the
    Mendelsohn is hard to do. But patients can do it right after being taught in x-ray.
<cathy lazarus> alot of clinicians can't do the Mendelsohn!
<cathy lazarus> some patients can actually do a combined mendelsohn and super
    supraglottic swallow, believe it or not.
<cathy lazarus> Patients will do whatever in order to eat by mouth rather than through
    the stomach tube.
<Adrienne FSU> what do we have to do to get the stomach tube removed?
<Adrienne FSU> are there definite criteria?
<cathy lazarus> It's a pretty simple procedure, but the patient has to be able to get
    enough calories and nutrition by mouth before a doc will pull it. There really aren't
    criteria, other than being able to get enough calories down by mouth.
<cathy lazarus> It's the doc's decision to pull the tube, but your input is critical.
<cathy lazarus> yes, or the patient takes less liquid supplements through the tube
    during the process. Some take nothing through the tube, but leave it in awhile just in
<RRS- BU> I hate to keep going back to this, but again if the patient is bedridden, you
    can't teach via xray....is there ever a case where you cannot get a patient to an xray
<RRS- BU> provided he is cognitively capable of performing the manoeuvers to begin
<cathy lazarus> Actually, we see alot of intensive care unit patients who are bedridden.
    They are transferred to a gurnee and come down to x-ray. Not everyone can get an
<cathy lazarus> Folks on ventilators are trickier-  either come down with respiratory
    therapy or portable ventilator.
<cathy lazarus> patients who are combative or refuse to come to x-ray are also not
    seen for swallow studies!
<cathy lazarus> Another group that doesn't make it to x-ray are those that are totally
    non-alert and too sleepy.
<RRS- BU> right.  Thanks!
<cathy lazarus> If they're that sleepy, etc. they couldn't sustain themselves anyways by
<kathy> dr L, would you say a "tongue thrust" is part of a swallowing disorder? if so,
    can you give us common Tx to address this with Ped population.
<cathy lazarus> I've never worked with someone with a tongue thrust. Myofunctional
    therapists do, not sure it's in our scope of practice, but it might be.
<kathy> ok.
<cathy lazarus> Actually, it is a bit part of a swallowing disorder, but they're tricky to
    work on and change.
<RRS- BU> Another question- typically how many times do you see patients?  Do you
    see them 1x- for dx & tx maneuver explanations, or on a more regular basis?
<cathy lazarus> If they are in the hospital, they are seen daily, or twice a day. I see my
    outpatients once a week or once every other week. Once they get the homework, I just
    need to see if they are doing it correct
<Anonymous464> I have a question about the whole sleepiness....my grandma
    sometimes " forgets " to swallow and we have to remind her....is there something else
    we could do to help her remember?
<cathy lazarus> That's a tough one, 464. It's hard to bring swallowing to the conscious
<Anonymous464> okay
<cathy lazarus> For some folks, we just tell the about every minute or so, to swallow!
<Anonymous464> thats what we have been doing :)
<cathy lazarus> whatever works!
<cathy lazarus> Some stroke and other neuro patients tend to swallow less frequently
    than the rest of us.
<kathy> Dr L, off the top of your head, can you recommend articles that you would
    highly recommend reading before working with swallowing pts.
<cathy lazarus> good question. I highly recommend Jeri Logemann's book, second
    edition. But if you need a review article, she's written a few on the merits of the x-ray
    study and also discusses how to treat swallowing problems.
<cathy lazarus>  She has a few in print. I don't have the titles off-hand, but if
    you do a lit search, you'd be easily able to find them.
<kathy> thank you.
<Shanna> Dr. L, you mentioned earlier that some patients actually refuse swallowing
<cathy lazarus> yes, some who have dementia refuse. Others who have lost the will to
    live, or who are depressed may also refuse.
<Robin> Dr. L, don't some patients just refuse to participate in tx, refuse to drink
    thickened liquids, etc?
<cathy lazarus> you bet. And there's not a darn thing you can do to make them do
    exercises or eat what you want. All you can do professionally is document, document,
<Shanna> Then what do you do? just leave them alone?
<cathy lazarus> You just let them know the risks of taking certain foods, such as
<cathy lazarus> I always tell my head and neck cancer patients who had radiotherapy
    that their swallow will likely get worse, not better if they don't do the exercises, from
    tissue fibrosis.
<RRS- BU> Dr. L- what's your opinion on FEES?  I know it 'whites out' during the
    swallow, but do you use it ever to get a different perspective on the mechanism?  
<Anonymous464> just wanted to say thank you for answering some of my questions
    tonight :)
<cathy lazarus> You could get a different perspective on laryngeal function (better than
    x-ray), but you lose quite a bit of info on the pharyngeal phase. You're welcome, 464!
<cathy lazarus> We don't use FEES to evaluate swallowing. We did a study looking at
    both the same time. You do get some info from FEES that you don't get from x-ray. Though
    you lose some too.
<cathy lazarus> FEES is also great for biofeedback and to let you know if a patient is
    doing a manuever correctly.
<RRS- BU> great info, thanks!
Shanna> What does FEES stand for?
<RRS- BU> Shanna- Fiberendoscopic Evaluation of Swallowing (or something along
    those lines)
<Anonymous1227> When medicare won't pay for an MBS or an MD won't make the
    referral do you consider the FEEs an alternative choice?
<cathy lazarus> You could, but they might not pay for a FEES either. I still wouldn't
    make diet recommendations if I don't have an instrumental examination.
<Anonymous1227> I feel the same way--but what do you do?
<cathy lazarus> You have to stick to your guns, and don't let whatever company you
    work for try to make you make those decisions if you don't feel comfortable making
cathy lazarus> you also have to give the docs ammunition - articles on the utility of the
    VFG/FEES studies. There are alot out there. Bonnie Martin-Harris did a good one on
    x-ray studies - in Dysphagia journal last
<Anonymous1227> Would you make a dietary decision with a FEEs only?
<cathy lazarus> 1227 - can't answer that since I don't personally use FEES, but I
    wouldn't recommend it
<cathy lazarus> You just miss too much info with FEES.
<Anonymous1227> There was one from yrs ago--Langmore vs Logemann
<Anonymous1227> Thanks for your input Dr. L
<cathy lazarus> yes, they don't fight as much these days! FEES definitely has it's place.
<Anonymous1227> Glad to hear that
<cathy lazarus> you're welcome.
<cathy lazarus> No point in not being flexible in your thinking about things. Just be wary
    about things that are new for therapy, like electrical stimulation, that have no or little
    data to back them up.
<cathy lazarus> thanks for coming on board to ask questions.
<Shanna> Yes, thank you
<kathy> thank you Dr. L!
<Robin> Any last questions for Dr. Lazarus?
<Anonymous1227> What do you think of osteopathic or myofacial techniques?
<cathy lazarus> not sure of osteopathic, but myofacial techniques I'm sure are useful.
<RRS- BU> Thanks for your time, and for sharing your experiences, Dr. L!
<Adrienne FSU> this was very informative, Thank you Dr. Lazarus!
<cathy lazarus> You're welcome.
<cathy lazarus> Good luck getting through your programs! And finding jobs.
<Anonymous1227> Thanks Dr. L
<Robin> Thank you so much for joining us tonight, Dr. Lazarus! 
<kathy> signing off. THANKS TO ALL>
<cathy lazarus> You're very welcome!
<Robin> Thank you all for coming tonight! 

<Anonymous8> ok thanks robin my e-mail is swannera@familyclick.com I would love
    some more info