Our guest chat host tonight on October 2, 2000 is Dr. Cathy Lazarus, from
Northwestern University.  Dr. Lazarus' 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.  Her work also involves 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 is the Swallowing Program
Coordinator for the 2000 ASHA Convention. Tonight she will chat about
assessment and treatment of swallowing disorders.

<Maggie> how do you diagnose a swallowing disorder
<Cathy> You perform a clinical examination,
    which includes an oral-motor exam and a swallow exam. Then, if you feel
    that there is pharyngeal phase swallowing problem, x-ray study.
<Adrienne> do you recommend thickened liquids?
<Cathy> not being able to swallow is very devastating.
<Katie> One of the swallow studies I observed did all of those
    things..it was very interesting
<Adrienne> and how do you decide how thick?
<Cathy> I only recommend thickened liquids if I cannot eliminate aspiration
    with postures, maneuvers, or a combination.
<Kelly> Gravity works?  :-)
<Cathy> Katie - good that you were able to see a decent study being
<Erin> did you know what you wanted to specialize in when you were
    our age....2nd year college kids?
<Cathy> Actually, i was a pre-med major and the first quarter of my freshman
    year I didn't do too well in chemistry and calculus and I was going to drop out
    of college, but someone told me NU had a speech program
<Adrienne> good question
<Katie> the liquids don't they enter into the trachea if they are too thin?
<Adrienne> that's what I was thinking
<Adrienne> gravity could almost be a bad thing
<Erin> wait, what do the liquids do in the first place?
<Katie> that is what happened with the older women I was
<Cathy> Liquids are the easiest to aspirate, since they move the fastest.
<Katie> they test the swallowing
<Erin> to get nutrients through their bodies without an IV?
<Katie> no
<Erin> oh, just for testing?
<Cathy> You typically give patients liquids, puddings, and a masticated
    consistency, like a cookie.
<Adrienne> just to clarify: aspiration is when food or liquid enters the trachea
    instead of the esophagus, yes?
<Erin> nevermind, i mean i am clueless....sorry
<Cathy> Yes, down in the x-ray suite. Yes, aspiration is just that!
<Kelly> That stuff tastes terrible-- had to eat some the other day for class!
<Katie> they let you observe the swallow on the x-ray
<Cathy> Yes, barium is not too pleasant tasting.
<Adrienne> what do they swallow?
<Adrienne> UGH
<Adrienne> Do you ever have patients that don't cooperate during the test?
<Kelly>  Dr. L-- saw a study where they mentioned mixing barium with
    blueberry syrup-- do you mix stuff in?
<Adrienne> or follow the recommendations afterward?
<Cathy> If you ever get the opportunity to observe swallow studies in x-ray,
    you should - they're quite interesting.
<Kelly> My professor laughed at the idea of "mixing" to improve taste
<Cathy> No, we don't mix much other than our standard consistencies. We'd
    rather take the time to check out the effects of postures and maneuvers on
    swallowing and you don't want to expose the patient to too much radiation!
<korissa> i just saw a video today with x rays of swallowing.  it was
<Erin> we've been discussing cleft palates a lot in our class, what kind
    of swallowing problems can occur as a result of those?
<Katie> you can also test regular foods so that the dietician at the
    hospital can have a good menu for the patient
<Cathy> Actually, folks with cleft palate usually compensate and don't typically
    exhibit swallowing problems, other than newborns, who do have difficulty
<Adrienne> mushed up food is still better than a feeding tube
<Cathy> yes, pureed foods still taste better than no foods.
<Adrienne> guess "mushed" isn't a technical term :~)
<Cathy> Mushed is just how some patients feel the food looks!
<Adrienne> do you have young patients or are they all elderly?
<Erin> what about a swollen or incompetent eustachian tube?
<Cathy> Don't think that should affect swallowing. Have never seen it do so!
<Anonymous9184> Dr. L, what kind of specialized training does a grad
    student need in order to pursue a CFY with neonatal swallowing?
<Cathy> Good question. You would want to request a practicum at a hospital
    facility that has a NICU.
<Erin> oh, i looked at neonates today for FSW, there was one with
    swallowing problems, he'd been there for a week
<Katie> Dr. L is it true that lowering the chin aids swallowing?
<Cathy> Yes Katie, lowering your chin can prevent aspiration in those folks
    with poor tongue control or a delayed triggering of the pharyngeal swallow.
<Kelly> Dr. Lazarus, do you work with other populations other than
    swallowing?  Did you start out in swallowing or focus there after a few years
<Adrienne> why do many premature babies have sucking problems?
<Cathy> Kelly - I started out working in a preschool special ed program. But
    they went on strike after the first day of school, so I needed to find another
<Kelly> lol
<Adrienne> wow!
<sw29> how did u like working in the preschool?
<Cathy> When I started working at Northwestern, I never had a swallowing
    course. It took 6 months to figure out what I was looking at when Jeri
    Logemann, the guru, did the swallow studies.
<Kelly> She wrote the book for our course!!!  Logemann!
<Cathy> Yes, she is my boss and has been for a very long time. She's a great
<Adrienne> what course Kelly?
<Kelly> I'm in a dysphagia (swallowing disorders) course this semester.
    Taught by Martin-Harris
<Cathy> Oh, Bonnie is great! Really good teacher and a good person. You'll
    learn alot.
<Kelly> Wow-- so far she's our favorite professor-- you can tell she "knows
    her stuff"
<Anonymous9184> if you haven't had any clinical practicum experience is it
    possible to still look into a job in neonatal disorders or should you wait until
    you have some experience first
<Cathy> I'd definitely wait til you have the experience. Actually, no one would
    hire you in a NICU if you didn't already have any!
<Anonymous9184> Cathy, do you work with all ages with regard to
<Cathy> yes, we see folks in the neonatal intensive care unit (NICU) up to the
    geriatric patient.
<Erin> are all of you at NU but like 3 of us here at Miami
<Cathy> I'd hook up with Donna Lundy at the U. of Miami - she knows alot
    about head and neck cancer treatment for voice, speech and swallowing
She's a really sharp clinician.
<Erin> thanks, though....i'm not sure about our swallowing specialists
<Anonymous9184> do you work with other disorders as well?
<Cathy> Yes, the majority of my caseload is voice disordered patients.
<Robin> Cathy, Adrienne had asked a question earlier, why do preemies
    have sucking problems?
<Cathy> preemies are delayed in their motoric and central nervous system
    development, which is why the suck/breath/swallow pattern can get screwed
    up, in simplistic terms!
<Adrienne> what can you do for preemies?
<Anonymous9184> I just recently got assigned a voice client, college-age
    singer with nodules.  Is there any therapy website or resource you can refer
    me to?
<Cathy> You know, there is a voice listserve, but I don't happen to know the
    address. I think it's out of U. of Iowa, Iowa City.
<Cathy> I'd also refer to your class notes, texts, etc. You have a supervisor,
<Maggie> Cathy, do you know of anyone at Miami Ohio who I can ask
    questions to
<Cathy> I honestly don't, but I'd contact the speech and hearing program and
    see if someone would be willing to talk to you. I'm sure they would. They're
    always looking for good students.
<Maggie> ok, thanks
<Cathy> Jamie, are you enjoying your program and have you begun to see
<jaime b> Yes, I love it.  It is a new grad program.  I also attended ACU as an
    undergrad and saw a few clients then.  Right now I have one new voice client
    but am doing most of my clinical work in an elementary
<Kelly> Dr. L-- is tongue thrust considered a swallowing prob?  I've got a
    client with tongue thrust at the elementary school where I'm getting clinical
    hours-- so far we're using oral-motor exercises
<Kelly> My supervisor is worried about the resulting artic problems, but I was
    wondering if there might be a swallow concern?
<Cathy> No, it's not considered to be a swaIlowing problem. It's a tough one
    to work on!
<Kelly> She's 11 and doesn't want to be in therapy-- we are using lots 'o
<Cathy> Artic problems are all you'll have with a tongue thrust, unless it's
    severe and if so, just will get alot coming out of the mouth at meals.
<Cathy> Bribes work well!
<Robin> Does any one have any questions about voice disorders?
<Cathy> Jamie - glad you like the program. Voice clients are fun, aren't they.?
    You can hear the results immediately.
<Adrienne> do you use computer programs with voice clients?
<jaime b> I was wondering about some resources to check out for a client
    with nodules.  She's a singer
<Adrienne> I was able to use a Visi-Pitch once...
<Cathy> Actually, we don't use computers, mostly because we can't send the
    patient home with the software and computer to practice. We'd rather get the
    patient to modify his voice without it.
<Cathy> Visi-pitch is good, offers visual feedback, but still can't send it home
    with the patient!
<Adrienne> right
<jaime b> I actually haven't met with her yet.  I am not sure where to start.  I
    will see her this week for the first time
<Robin> what are some of your most useful therapy techniques for nodules?
<Cathy> Well, modifying their everyday behavior to start - quitting yelling,
    throat clearing, loud talking. Then move to modifying the pitch, loudness,
    breath support or airflow when they speak.
<Cathy> Just raising their speaking pitch and getting a bit more out out when
    they speak works wonders.
<Robin> What is your success rate with pts with nodules ?
<Cathy> Pretty high, as long as they stay motivated! Only takes 6 to 8
    sessions, typically.
<jaime b> do you follow any particular program?
<Kelly> What do you do if you have someone who yells for her/his job?  i.e.
<Robin> Dr. L is the expert for this!
<Cathy> I see traders at the Chicago Board of Trade who yell in the pit. I teach
    them the "correct" way to yell that won't hurt their voice.
<Cathy> It's also fairly easy to teach folks like teachers, trial lawyers, etc. how
    to project their voice.
<Kelly> Is it too complex to explain "correct yelling" on the chat?
<jaime b> where do you find your techniques that you use in therapy
<Cathy> It's a bit difficult, but I'll try. You teach them to breathe
    diaphragmatically, then work on how to exhale rapidly while they yell so they
    won't hurt the vocal folds. then you work up from single word
<Cathy> to phrases and to then be able to yell repeatedly, which they do in the
<Kelly> Thanks!
<Adrienne> do people generally come to you for tips on "correct yelling" or do
    you recruit from where they work?
<Cathy> I learned a lot of my techniques from an old professor of mine, Hilda
    Fisher, PHD (of the Fisher-Logemann test of articulation competence fame!
<Cathy> I get most of my voice clients from referrals from our ENT docs.
<jaime b> do you know of any books/websites for us to look into?
<Cathy> Jaime - you mean for therapy techniques? In voice, Joseph Stemple
    has a good book out.
<jaime b> yes, thank you
<Cathy> Most folks are willing to have a student tag along for a half-day or so
    to observe treatment, if you're thinking of getting your masters.
<jaime b> do you have any advice for those of us that are about to head out
    into the "working world" of SLP
<Cathy> Jaime - yes, I'd say don't do anything you are uncomfortable doing or
    that you are unsure of - ask another SLP or your supervisor. Question things
    and if you don't know something - look it up!
<jaime b> thanks for the advice
<Kelly> Do you work with Alzheimer's patients at all? 
<Cathy> Kelly - yes, we see them for swallow evals, but not typically for
    speech therapy.
<jaime b> what is your favorite disorder to work with?
<Cathy> I love to work with the voice clients and also with the head and neck
    cancer patients - they are all cognitively intact and can do everything you ask
    them to do and are typically very motivated.
<Kelly> What's a common swallowing problem for that type of patients?  My
    grandpa has Alzheimer's, and he's changing his "tastes" radically-- we don't
    know if it's mental or physical
<Adrienne> that's interesting
<Cathy> Yes, Alzheimers disease is tough - your sense of taste, food
    management in general changes over time. Kind of a combination of mental
    and physical.
<Adrienne> is that common in people with Alzheimer's?
Cathy> Yes, Alzheimers's causes one at a certain point to not recognize food
    within the mouth. We can do an x-ray study and the patient will start talking
    while the food is in his mouth.
<Adrienne> Does Northwestern see any neurogenic disorders?
<Cathy> Adrienne - yes NU does see LOTS of folks with neuro disorders.
<Kelly> Wow.  I think I need to look into that area. 
<Cathy> No, really, the coursework is good and there are lots of options for
    hospital and school placements.
<jaime b> how long do you need to work in a practicum site for it to be
    considered "experience"
<Cathy> One quarter counts as "experience".
<jaime b> as in 3 months?  can you count it as experience even as a student
<Cathy> AT NU it's a school vs. hospital track. You can see both kids and adults
    and do a school placement and still see adults.
<Cathy> Actually, our quarters are only 10 weeks, but you'd be surprised what
    you can learn in 10 weeks in a half day or full day weekly practicum.
<Adrienne> would you say NU is more clinically or research oriented?
<Cathy> Yes, we need more researchers in our field - too many of the faculty
    are retiring!
<jaime b> if you are wanting to pursue a particular area that you do not have
    clinical experience in would you suggest spending 10 weeks in that area and
    then applying for a CFY or begin your CFY in something else?
<Cathy> Yes, you can always take a clinical job and use your patients for
    research studies.
<Cathy> Jamie - I'd try and get a broad base of experience in the master's
    program, to get at least a little experience in the area of interest. Hospitals
    want you to have some hospital experience, FYI!
<Adrienne> will I have any input into where my CFY is?
<Cathy> yes, your CFY is wherever you can get a decent job that sounds
    interesting to you!
<Robin> tell us about the research you're doing with tongue strength.
<Cathy> Robin - I've been having normal healthy subjects do tongue
    strengthening exercises and then assessing whether tongue strength
    improves. Also have a control group that get no exercises
<Robin> how do you measure tongue strength...with what kind of
<Cathy> Robin - I use the IOPI - Iowa Oral Performance Instrument - comes
    out of U of Iowa, costs $1200.
<jaime b> I am wanting to work in NICU, however, the hospital in my area
    doesn't have an NICU
<Cathy> Jaime - there aren't alot ot those around - see if you can do some
    sort of internship at another hospital.
<Cathy> Adrienne - you probably will if you get some good experience in grad
<jaime b> Adrienne, your clinical practicum experiences will help you get a
    feel for what area you want to go in to.  You will most likely surprise yourself
<Adrienne> neat :~)
<Cathy> Glad to have chatted with all of you. I need to go too - my dog is
    bugging me to go out!
<Kelly> Thanks
<Robin> Cathy, thank you so very much for joining us!
<jaime b> thanks for all of the helpful info, Dr. L
<Adrienne> Thank you so much for coming to talk with us!!
<Cathy> Robin - Thanks for the opportunity to have been in this chat!
<Cathy> Good luck to all of you in school/ work, etc.!