Are you sure that’s impaired? The swallowing norms you’re using might not be as meaningful as you think.
Imagine this: you hear about a new test of an Important Swallow Measure and check out the article for its normative data. You see this table:
The next day, you try out the test and your 25-year-old patient scores 1.57 seconds.
Is their Important Swallow Measure within normal limits?
Hold that thought while we consider what within normal limits even means.
Whenever we make a clinical judgement, we’re doing some kind of assessment of whether the patient’s behavior is normal, functional, or disordered. Often, we collect quantitative data from our patients and then want to see how their performance compares with “normal limits.” To define those limits, we typically ask: What are the lower and upper values that include the vast majority (commonly 95%) of the results from a healthy sample?
In some areas of our field, finding these values might be relatively straightforward, like a score on a published norm-referenced cognitive assessment. But a lot of the normative data for up-and-coming quantitative measures of swallow function are coming straight from research articles that aren’t trying to provide a normal range (like this one). These articles might look like they present the data we want—even when they don’t. So we need to be careful not to accidentally use the wrong values to make clinical judgements, just because they are the only values available.
There are a number of appropriate ways to define a normal range. For example, we might use +/- 2 standard deviations (SD) from the mean to capture ~95% of the normal values (if we know the data is normally distributed). Or, we could define normal limits based on percentiles (especially if the data is skewed). For example, 90% of US women’s heights fall between the 5th percentile of 4’11” and the 95th percentile of 5’8” . If you don’t remember much about SD and percentiles, don’t worry. Just know that these are both meaningful ways to describe a range within which most of the values fall. And, therefore, they are good measures to use when defining normal limits or thresholds.
Now let’s go back to that table. Is your 25-year-old patient’s score of 1.57s within the normal range?
On a recent social media post, we asked our followers to tell us about a topic they wanted to learn more about. The most popular response? Chemo brain, also called chemo fog.
You asked, we answered. Read on for:
Five facts + twelve clinical takeaways about chemo brain
“I lost the capacity to multitask and to hold a string of ideas in my head. I groped for the right word that I knew would express what I wanted to say, and lost the ability to hold a thought in my mind if I had to wait a few minutes for my turn to speak. It felt like a mental fog had descended over me; I might begin a sentence knowing what I wanted to say, but by mid sentence I’d lost the sense of it and stumbled finding the words or had to stop speaking altogether. I could no longer do crossword puzzles; I would remember that I used to know the word, it might sit just out of reach in my mind, but I could no longer reliably retrieve it. I used to always rely on a nimble mind and strong facility with language, but could no longer trust my mind or memory. I lost the ability to discuss a book. I’d struggle to remember something I’d just read. Some of this has improved over the years since my transplant, but much has remained.” ~ On living with chemo brain, contributed by Susan Evans (mom of TISLP Editor Karen)
I was on the plane to Orlando, heading to the ASHA Convention. I realized I had an issue of the ASHA Leader in my carry-on, so I pulled it out to browse through. I was thumbing through the pages when I saw a page full of brief quotations. The question at the top of the page read, “How are you incorporating diversity into your clinical practice?”
Respondents from all over the country shared their diversity initiatives. One SLP said, “We’re hosting an international night! Folks will bring foods that represent their cultures to share with everyone.” Another SLP shared, “We’re decorating the halls of our school to represent the different cultures of the world.” Yet another suggested something like, “We’re celebrating African-American History month with literature about the underground railroad.” I immediately stuffed the Leader back into my bag and pulled out my laptop. I had completed my presentation days ago on misdiagnosis of speech sound disorders in bilingual children, a topic I speak on nearly every year; however, I felt compelled to add a couple slides. The first listed the quotes I found in the Leader article. At the bottom of the slide I wrote in all caps THIS IS NOT ENOUGH.
Maybe you’ve said the following:
“Where are you from? No, where are you REALLY from?”
“You speak English really well for a ______ person!”
“Can you teach me words from your native language?”
“What are you?”
“You don’t look ______.”
But let’s think again. What makes me assume I know your culture and who you are from visual appearance?
The previous statements are actually considered to be microaggressions. They send the message that an individual is “other”, “different”, or “less-than” in some way. Sue et al. (2007) identifies microaggressions as daily verbal, behavioral, or environmental insults that can either be intentional or unintentional, and that can impact clinical interactions between a clinician and client.
What does culture mean to you?
Tell me what is most central to your identity:
Is it your age?
… or something else?
If you had a hard time choosing one you probably, like most people, fit into more than one category. Oftentimes culture operates at a place of intersectionality. One box does not fit all areas of your cultural identity. Culture is the fabric that makes you who you are and is always evolving. But importantly, our assumptions about culture shape our interactions with our clients. These are the invisible biases that can prevent a clinician from being qualified to practice.
Say hello to the: Early 13, Middle 7, and Late 4?!
Quick: For those of you who are already caught up on the article that broke the SLP internet, the TL;DR version of this newer article is:
Everyone else, welcome! Let’s go on a journey together. Consider this topic an enchanted forest; the path through may be arduous, but we will all leave with our practices transformed for the better. Is it possible that quarantine at our house is involving a lot of Frozen 2? Perhaps.
members of The Informed SLP
Blog posts by title:
In a fog: Five facts + twelve clinical takeaways about chemo brain
#AmIQualified: Let’s talk about bilingualism and white supremacy in CSD, one layer at a time
#AmIQualified: Let’s talk about privilege in speech–language pathology
#AmIQualified: Let’s talk about moving from cultural competence to cultural humility
The Not-New Speech Norms Part 2: An American Tale
Motivational interviewing and behavioral change in clinical practice
Standardized language tests: That score might not mean what you think it means
The grammar guide you never knew you always wanted
Top 12 questions about ASHA CEUs—answered
Schools, safety, SLPs, and the evidence
Response to #BlackLivesMatter, 2020
COVID-19 and Dysphagia: Considerations for the Medical SLP
COVID-19 and Cognition: Impact for the Medical SLP
Looking for evidence on telepractice for SLPs?
"I don't get what the difference is between ASHA's Evidence Maps, speechBITE, and The Informed SLP..."
SLPD vs. PhD: What's the difference?
That one time a journal article on speech sounds broke the SLP internet
The difference between respecting our science and loving our science
What does the evidence show about treatment intensity?
EBP as a blame game
The EBP barrier nobody is talking about
Guest post: On evidence analysis
Guest post: On trauma and language development
Guest post: Working memory, processing speed, and language disorder
Guest post: Push-in services—how to collaborate!
Guest post: Complexity approach for speech sound disorders
How am I supposed to find time to read research?!?
SLPs: How to make sure you're using EBP
SLPs: How to get access to full journal articles