History: A 56-year-old truck driver was forced to retire early because of progressive weakening and cramping of his arms, hands, and legs over the course of two years.  According to his spouse, shortly after his retirement, he began to regurgitate liquids through his nose, choke on foods, demonstrate slurred speech, and experienced progressive weakness of his upper extremities.

ID of likely communication limitations: The difficulties that the 56 year old truck driver is experiencing would indicate Amyotrophic Lateral Sclerosis ( ALS). Also, the fact that he is male and involved in the physical activity of driving a truck are other indications of ALS.  There is no cure for ALS.  It is progressive in nature.  The communication characteristics associated with ALS vary depending on the type of dysarthria present. (flaccid/ spastic)  Individuals with ALS have the following speech characteristics:
1. Defective articulation of consonants and vowels which lead to unintelligibility 2. slow production of words in very short phrases 3. hypernasality along with harshness and strained-strangled squeezing out of low pitched sounds 4. Complete disruption of prosody 5. Monotony, excessive intervals between words and phrases 6. profound weakness 7. Lack of oral movement 8. reduced phonatory production 9. tongue weakness 10. decreased voice quality 11 decreased speech intelligibility

The rate of decreased intelligibility depends on the site of initial symptoms.  Those with initial bulbar symptoms exhibit more severe speech problems that those who exhibit spinal symptoms.  Deterioration of speech is usually evident with ALS.  However, individuals can continue to communicate with the use of compensatory methods and alternative communication devices.

Sources:
Duffy, J.R. (1995) Motor Speech Disorders. St. Louis: Mosby

Yorkston, K.M., Miller R.M., & Strand, E.A. (1995) Management of Speech and Swallowing Disorders in Degenerative Diseases. Tucson: Communication Skill Builders.

Submitted by: Christie Phelps and Hope Moorman

ID of likely swallowing limitations: From the history presented, it is apparent that this individual suffers from bulbar-type ALS.  Several of the swallowing difficulties were mentioned in the history.  However, let's consider the underlying
problems. Damage to the corticobulbar tracts would result in damage to the cranial nerves necessary for intact swallowing.  Compromised innervation would result in progressive weakening of all motor structures, thus, the nasal regurgitation, slurred speech and apparent aspiration.

What might cause the aspiration?

We already know that he has slurred speech indicating potential tongue weakness.  Such an indication would lead us to suspect impairments in bolus preparation and transit.  Dyscoordination in the oral cavity could result in aspiration before the swallow.

Now let's consider potential problems further down the system.

The problem with innervation may also translate into impairment with the elevation of the laryngeal framework.  We know that such an impairment may result in an airway that is not fully sealed during the swallow.  So aspiration during the swallow is a possibility.

Finally, the generalized weakness demonstrated by all oral-motor structures and laryngeal elevation musculature may also be present in the pharyngeal constrictors.  Decreased pharyngeal contraction would result in stasis in the pharyngeal recesses and the potential for retention aspiration, or aspiration after the swallow.

As noted, this individual is at high risk for aspiration anywhere along the continuum of the swallow.

Submitted by Julie Stierwalt

ID of likely limitations in simple ADL's: ALS is a degenerative process which destroys motor neurons in the cortex,
brain stem, and spinal cord.  It causes weakness and muscle atrophy. Initial symptoms of ALS include patients complaining of an inability to perform functional tasks, such as dressing and eating.  Weakness occurs throughout the body, affecting all ADLs.  A decrease in muscle strength, ROM, muscle tone, endurance, and soft tissue integrity are common in ALS patients, therefore causing limitations in all basic ADLs.  For example, the patient will have difficulty putting on a shirt and pants, going to the bathroom, eating food, brushing hair, shaving, and bathing self due to muscle weakness and fatigue.  Because ALS is fatal, the patient is issued adaptive equipment to maintain independence for as long as possible. This will allow the patient to become more independent in basic ADLs; thus improving the limitations.

References:
Neistady, Maureen and Elizabeth Crepeau.  (1998).  Willard and Spackman's Occupational Therapy.  (9th ed.)  Philadelphia:  Lippincott.
Trombly, C.  (1995).  OT for Physical Dysfunction.  (4th ed.)  Baltimore: Williams and Wilkins.

Submitted by:  Amy Hahn

ID of likely limitations in complex ADL's:  ALS is a progressive disease characterized by muscle weakness, atrophy, and eventual spastic paralysis. It progresses distally to proximally, therefore his Fine motor skills will be affected first. Gross motor and endurance problems will also affect his ADLs.

Deficits in Complex ADLs (IADLs) are as follows:

*Job Performance: as was already noted, the disease progressed so that he was forced to retire. The affects of muscle weakness and decreased endurance would cause difficulty in driving his truck as well as performing other responsibilities of the job such as repairs and loading/unloading the truck.

*Household Maintenance: Difficulties will be seen in ability to do housework, use appliances, and making home repairs such as plumbing/painting, yardwork (gardening/mowing, etc).

*Money Management: Poor fine motor coordination will make it difficult to write checks and therefore to pay bills.

*Functional Communication: Poor fine and gross motor skills will cause difficulty picking up and dialing the phone, using computers/typewriters, writing letters, etc.

*Meal Preparation and Clean-up: Difficulty managing appliances, dishes, etc.

*And last but not least, he will have difficulty manning the remote control for the T.V. :)

Submitted by Leslee Holt

Source:
Daniel,M.S. & Strickland, L.R.Occupational Therapy Protocol Management in Adult Physical Dysfunction.(1992).Gaithersburg:Aspen Publications.

Assessment of swallowing:  ALS is characterized by muscle weakness, which affects the swallowing process in affected individuals.  Assessment of swallowing in ALS patients is done through the use of many tools.  The first of which is dysphagia screening where the clinician observes the patient at mealtime.  A medical chart review and a medical staff interview should be done prior to the screening.   Those reviews will provide information such as: medical history of the patient, weight loss, dysphagia symptoms, respiratory conditions, current medications, the patients cognitive, speech, and swallowing abilities, and management of their oral secretions.  The clinician should be noting any coughing, choking, drooling, multiple swallows, differences in respiratory patterns, and throat clearing.  Many of these can be indicators of aspiration.  It also brings the clinician one step closer to determining the difficulties the patient is exhibiting in each phase of the swallow.  From here based on the findings the clinician can recommend a bedside evaluation to further explore the phases of the swallow.
 The bedside evaluation begins with an examination of the oral structures.  The clinician is looking for facial symmetry, dentition, and the strength and range of motion of the tongue. A speech sample is also obtained to assess comprehension and articulation.  The patient is asked to hold a sustained “ah” which provides information about vocal quality and palate function.  The oral mucosa should also be checked for signs of thrush or leukoplakia.  Through sucking and biting techniques reflexes can be measured.  A clear description of the symptoms directly from the patient is very helpful.  This may be difficult to obtain if the patient has a trach tube or is on a ventilator.  An evaluation tray is prepared prior to the evaluation which consists of varied consistencies.  The dyphagia screening gives the clinician an idea of what foods the patient manages the best.  Vocal quality should be checked prior to and after the swallow by cervical auscultation.  The bolus should be followed from the point it enters the mouth to the trigger of the swallow.  This can be accomplished by using the four-finger method, which assesses laryngeal function.  After the swallow has been completed the oral cavity should be checked for residue or pocketing in the buccal cavity. If there are no signs of coughing, aspiration or residue the clinician proceeds to a thinner consistency, always being administered in small amounts.  From this data the clinician decides if a further probe into all areas of the swallow are needed.  If so a videofluoroscopy can be recommended.  This allows the clinician to see the pharyngeal and esophageal phases of the swallow which are hard to assess by  a beside evaluation.
 The videofluoroscopy is performed along with along with a licensed radiologist.  This procedure allows the clinician to view any aspiration or pooling that may occur in the valleculae or pyriform sinuses.  Materials used are liquid barium, esophatrast,  semi-solids, and solids.  A person suffering from ALS in the oral phase might exhibit a poor labial seal, opening and closing of the mouth, premature spillage, pocketing, and decreased tongue strength, (they have difficulty with thicker viscosity’s and decreased strength in sucking).  In the pharyngeal phase the patient may have a delay in the trigger of the swallow due to weakness in the muscles of the throat. velar function may become impaired, difficulty with closure of the vocal folds, and aspiration and penetration are common.  The esophageal phase may be characterized by weakened peristalsis causing food to get caught in the throat, and reflux.  During the videofluroscopy the clinician should note how the patient manages various consistencies in each phase.
 Once information has been gathered recommendations can be made such as daily treatments to remedy dysphagia symptoms, feeding management, and aspiration precautions.

Submitted by: Amy Buzzetta

Sources:
Marta S. Kazandjian. Communication and Swallowing Solutions for the ALS/MND   Community.(1997). Singular Publishing Group.
Jeri A. Logeman. Evaluation and Treatment of Swallowing Disorders.(1998). Second Edition. PRO-ED, Inc, Austin, TX.
 

Assessment of communication: ALS is a motor neuron disease that impacts the upper and lower motor neurons of both the bulbar and spinal systems.  For many/most individuals, cognition and language are intact.  Thus, our assessment would focus more on speech production and language/cognition would be only screened and then evaluated further if indicated.

When evaluating speech production, we would look at the impairment, disability, and handicap levels across each of the speech subsystems. At the impairment level, we would assess respiratory function, preferably in conjunction with a respiratory therapist. Measures such as vital capacity, flow, and pressure might be obtained. Phonatory status might be assessed through maximum performance tasks such as s/z ratio or even directly observed under endoscopy.  The resonatory system might also be observed using nasendoscopy or non-instrumentally via elicitation of reflexes or other non-speech movements.  The articulatory system would be assessed systematically during an oral-motor exam.

The disability level might be assessed used a perceptual rating scale such as Darley, Aronson, and Brown, where characteristics of each of the speech subsystems, prosody, and intelligibility are systematically rated during reading and/or connected speech.  Published tests, such as the Dysarthria Profile and the Frenchay address both the impairment and disability levels of the subsystems.

Handicap or societal limitation will most often be assessed via self or family report, but we might also directly observe how communication limitations impact daily life by conducting a home visit, or at the very least observing communicative interactions among the patient and his family.

One factor that can be tricky to get at but is important in degenerative disease is an estimate of rate of progression.  You will observe performance at one "snapshot" in time, but it will be important to have a sense for how long it took to get to this point, in order to best plan for the future.

Finally, we will want to assess the ability to use strategies for improving/maintaining communication.  This would probably include identifying potential aug comm systems.

submitted by Heather Clark

Assessment of basic ADL's: Prior to assessing a client's BADLs, the OT will also need to assess several factors about the client.  The OT must look at the client's physical abilities to determine his potential deficits in ADLs.  This
would include things such as strength, range of motion, coordination, sensation, as well as cognition and perception.  The OT should also consider other factors such as the environment in which the client will be peforming his BADLs, the client's culture, the client's values and the balance of activities in the client's day.  Each of these may influence how many ADLs the client can perform independently.  Assessing these factors will help give a more complete picture of the client, his needs,
his strengths, and potential resources.
     Many times BADL assessment begins with an interview.  This self-report can sometimes help direct the evaluation to the areas in which a client may be having the most difficulty.  An interview alone is not an adequate assessment because the client may overestimate or underestimate his abilities.  Therefore, the interview is followed by an observation of
BADL tasks.  It is important for the OT to be respectful of the client's dignity during this assessment/observation.
     Often a client's BADL performance is rated by the FIM (Functional Independence Measure) scale.  The FIM scale is a scale of 1-7 that measure the amount of assistance that the client needs.  1=dependent; 7=indpendent. The client is rated on the FIM scale at admission and discharge from a rehab hospital as a way of documenting progress.  Often goals are set using the FIM scale as well.
     Some standardized ADL evaluations include:  Katz Index, Revised Kenny Sefl-Care Evaluation, Barthel Index, and the Klein-Bell Activities of Daily Living Scale.

Katz Index:  This evaluates 6 functions.  The score is determined by otogenetic development of self-care skills.

Barthel Index:  This index evaluates 10 functions.  Functions are weighted by importance and independence.  Scores range from 1 to 100 with 60 as the transition from dependent to assisted independence.

Kenny Self-Care Evaluation:  This included 7 categories.  These categories are broken down in to specific tasks.  Each task is scored individually.  All the scores are then added together.

Klein-Bell ADL Scale:  This test evaluates BADL skills which are broken down into tasks.  There are 170 tasks on the scale.  The tasks are scored 1) achieved (no assistance) or 2) failed (assistance required).

There are two assessments which look at ADL performance and safety: The Safety and Functional Evaluation (SAFE)
 The Safety Assessment of Functionand the Environment for Rehabilitation  (SAFER)

In addition, The Additive Activities Profile Test (ADAPT) looks at ADLs in relation to physical fitness.

All these assessments would most likely not be used for this client.  The OT would probably begin with an interview and then observe the client and rate him on the FIM scale.  The other assessments could be used, if the OT
wanted a more detailed assessment.

The thing that is very important to remember for this case is that this client has a progressive disorder.  The client's abilities to complete his ADLs will decrease as the disease progresses.

References:

Pedretti, L.  (1996).  Occupational Therapy:  Practice Skills for Physical Dysfunction.  (4th ed).  St. Louis:  Mosby.

Trombly, C.  (1995).  OT for Physical Dysfunction.  (4th ed.)  Baltimore:  Williams & Wilkins.

Submitted by:  Shanna M. Hughes

Assessment of complex ADL's: I would first do an interest checklist and a pie of life to find out his responsibilities and leisure activities because this would give me a greater knowledge of what to assess and what to look for when assessing.
Since I do not have this information, I would proceed as follows:  I would do a manual muscle strength test which would let me know his AROM, his ability to move against gravity, and how much of a load he would be able to tolerate for carrying items (ex. could he pour a 1/2 gallon of gas into a lawn mower?). It is important for patients with ALS to avoid fatigue, so
I would look at his activitiy tolerance in minutes in order to recommend how often rest breaks should be taken (if he was mowing grass, etc.) and warn him about activities that would be too strenuous for him (using a push mower).  I would give the Jebsen-Taylor Hand Function test (coordination) because of his cramping and weakness.  This would give me
an idea about his writing and typing ability and ability to manipulate small object (like coins, utencils to cook with, manipulate a key to get into his house).  Since ALS does not affect cognition, I would assume that he can still mentally do activities like keeping up a checkbook and paying billls for money management - only his physical deficits would prevent him from completing activities previously done.  As a final overall assessment, I would use a home management evaluation.  This would let me know his abilities in housekeeping, preparing food, spending money, doing laundry, traveling (in home and community), and child care (although this aspect is probably irrelevant unless he has grandchildren).

Case study completed by jonese@mail.lrc.edu (Erika Jones)

Prognosis:  Because ALS is a rapidly progressive disease, the prognosis for recovery is poor.  The survival duration can be predicted based on several factors. First, age of onset: because this man's onset occurred after the age of 40, his survival rate is decreased.  Studies suggest that the older the person is at onset, the shorter the survival time.  Second, type ofinitial symptoms:  because this man's initial symptoms involved his spinal nerves, his odds of surviving five or more years is 3 times greater than if he had the initial bulbar symptoms. Third, pulmonary status: since this man is at risk for aspiration, we know that aspiration pneumonia is a threat.  This obviously puts his pulmonary system at great risk. Any negative condition to his respiratory status puts him at higher risk of mortality.  Finally, psychological factors: We don't know his psychological status based on the case background.  However, research shows that death rates are much lower in individuals with ALS who have a high psychological well-being" as opposed to those with psychological distress.  In fact, psychological distress alone (with all other factors controlled) puts individuals with ALS at much greater risk of mortality.
 The major focus for this man should be on management of symptoms. In particular, treatment for his swallowing difficulties should be addressed ASAP.  He will, more than likely, stay in his home supposing he has family support or until they can no longer care for him in the home. Those providing service to this individual should provide as much encouragement to maintain ADLs and education as possible.
 In summary, we know this man has been dealing with symptoms of ALS for at least a couple years.  The eventual course and outcome of ALS are bleak.  Most patients indicate that there is no good way to tell a person "you have ALS."  Patients appreciate physicians who were straight forward and honest but not premature, sensitive to patients readiness for
information, and able to convey some degree of hope.

Submitted by Karen Tedesco

Source: Yorkston, K.M., Miller R.M., & Strand, E.A. (1995) Management of Speech and Swallowing Disorders in Degenative Diseases. Tucson: Communication Skill Builders.

Swallowing targets and activities: Given the progressive nature of corticobulbar ALS and its inevitable impact on swallowing, it would be beneficial to discuss the need for compensatory devices and/or intervention with the client as soon as possible.  Therefore the first functional goal would be to provide information and education to the client and his family about this issue.  Decisions regarding enteral feeding options, augmentative devices, and direct care providers should ideally be made before these services are required.
    Despite the client’s diagnosis, it is essential to maintain his quality of life as long as possible.  Therefore, the second functional goal would be to reduce the risk of aspiration while maintaining adequate nutrition and hydration by mouth as long as laryngeal function is capable of protecting the airway.  Since active exercise will likely fatigue the client’s system, the implementation of  compensatory techniques is recommended.  Due to the reduction of mobility in the oral structures, the client will have difficulty with foods of a thicker consistency. Gradually modifying the diet by changing the consistency of food to liquids and thin paste will allow him to have oral feedings for a longer period of time.  In addition, foods of mixed consistencies such as cereal or vegetable soup are not recommended.  To combat a delayed swallow reflex, thermal stimulation could be performed several times throughout the day, especially before meals.  A therapeutic technique such as the chin tuck position could also be helpful.  This positioning would prevent premature spillage into the pharynx and help to elevate the larynx.  It would also help to invert the epiglottis, which would seal the airway and bring the pharyngeal walls closer together.

Reference:  Logeman, Jeri A. (1998).  Evaluation and Treatment of Swallowing Disorders (Second Edition).  PRO-ED, Inc, Austin, TX.
Submittted by Chrissy Schatz

Basic ADL targets and activities: These goals would be appropriate for this patient with ALS in regards to his basic ADLs.

1)  Pt will brush teeth with minimal assistance.
Activity:  Pt could use the hand helper or retrieve items from theraputty to maintain muscle strength in hands.

2)  Pt will wash upper body with moderate assistance.
Activity:  Pt could use arm bike to work on endurance, or practice various range of motion activities, such as the BTE machine or shoulder arch.

3)  Pt will don pants with minimal assistance.
Activity:  Pt could practice using a dressing stick with a built up handle, or could practice various techniques of pulling up pants, such as side-to-side, or laying down.

With all these goals, the best activity is to practice the actual activity being worked on.  This pt might benefit from using various adaptive equipment such as a universal cuff, a dressing stick, enlarged/built-up handles, and long-handles items.  Pt and family education would also be a priority, along with teaching the patient some energy conservation and work simplification techniques.  The main goals would be to maintain his independence with his ADLs, maintain strength, ROM, and endurance, and to
educate him on a home exercise program that he could participate in.

submitted by Erin Maguire

Complex ADL targets and activities:  If pt were in further stages of the ALS the following goals would be appropriate.

Goal 1:   Pt. will retrieve clothes from closet with modified independence.
Activity:    Pt. will use the clothes pin tree to help keep endurance and the motion of reaching up as long as possible.

Goal 2:   Pt. will use telephone for social and emergency purposes with modified independence.
Activity:    Pt. will work with velcro checkers to keep fingers limber as long as possible.

Goal 3:  Pt. will communicate through writting with modified independence.
Activity:   Pt. will practice writing with various built up handles to chose which is best suited for him.

If anyone needs more clarification just let me know.

submitted by Jamie Mason

Communication targets and activities:  The first issue that needs to be address is the education of the patient and his family.  We have to be sure that they understand what to expect as the disease progresses.  They should be informed of steps that should be taken for transition between stages, and the various resources available (i.e. support groups, augmentative communication).  This should be done as early as possible in the intervention.

The patient is in the early stages of ALS and his primary communication complaint is slurred speech.  Targets for intervention should address this current complaint as well as offer compensatory strategies to improve/ensure effectiveness of communication.  It is also imperative to introduce and familiarize the patient with compensatory and therapeutic
strategies that can be implemented as the disease progresses.  This type of "early intervention" will enable the patient to modify his communication strategies in correspondence with the progression of his disease.

Compensatory Strategies for Mild to Moderate Dysarthric Speech Disturbances:
     As other people begin to have difficulty understanding the patient, various environmental manipulations can be implemented to aid in overall comprehension.  For instance, excessive environmental noise can make communication quite difficult for a patient with poor respiratory support who may be unable to increase his volume as needed.  Therefore, it is a
good idea to reduce surrounding noise when possible or move away from the source of noise.  Face-to-face communication and maintaining a slow speaking rate also promotes speech intelligibility.
     As the patient's dysarthria worsens and his speech becomes less intelligible, other compensatory strategies can be used to facilitate effective communication.  Because predictable messages are better understood than unpredictable ones, the patient may find it helpful to clearly establish the context of his message by introducing the topic at the beginning of the conversation and with each conversational change. This can easily be done by using the phrase, "I want to talk about..."
When interacting in groups, the size of the group should be minimized, if possible, because the rapid turn-taking and fast pace of group interactions can frustrate and ALS patient.  A good way to conserve energy and avoid fatigue is to discourage the person from exercising in the hope of strengthening weakened muscles, as there is no evidence that exercising
will improve the speech of people with ALS.  Finally, during these early sages of the disease, it is a good idea to develop strategies for resolving communication breakdowns, such as using signals for alerting the speaker that the message was not understood, selective repetition, or rewording the message when necessary.

Therapeutic Strategies fo Mild to Moderate Mixed Dysarthria:
     With progressive diseases, it is important to focus on the communication function rather than speech impairment.  As stated above, exercises for tongue and oral movement, as done with flaccid dysarthria, can be counterproductive.  There is some evidence that exercising to fatigue hastens neurological deterioration.  Patients can also become more aware of the progressing by these drills as well.  Therefore, it is necessary to introduce the different types of compensatory strategies that
can be used, aid in the decision of which ones work best for the particular patient, and monitor to make sure the patient is using the strategies appropriately.  As remember that the patient is an individual and treat him that way.

Although effective communication has not been shown to influence a patient's length of survival, maintenance of communication helps preserve a patient's sense of control over medical and personal aspects, as well as improve his overall quality of life as the disease progresses.

Submitted by Dawn Hill and Michelle Keilen

Resources:
    Management of Speech & Swallowing-Yorkston,Miller, Strand
    Motor Speech Disorders-Duffy

Review & Question: In our discussion, augmentative communication was mentioned as a subject to be discussed with family members and patients.  As we all know, many times one augmentative communication device will not be sufficient throughout the course of ALS.  Should all ACC options be discussed from the outset or should each option be discussed as the need for new devices arises?  Also, you did not mention specific devices that are most appropriate for ALS patients.  Did you find any that provided better results for patients while doing your research on this topic?

Julie Bradshaw

The Pt. with ALS and his/her family should be counselled and educated about using different types of AAC devices.  The AAC devices should be gradually introduced, usually beginning with "light-touch" solutions for specific communication needs. The family and Pt. needs to understand that ALS is progressive, and that the Pt's communication needs will change as the disease progresses.  If the Pt. and their family are prepared, they can make an informed decision about which AAC device to use.  As a SLP, you can prepare them by assessing the Pt's communication environments and determining their needs, wants, and functions necessary for affective communication in the pt's everyday life. At first, the Pt. will need an AAC device as a secondary means of communication for specific needs.  As the disease progresses, more technologically sophisticated solutions will be needed. AAC devices should be tailored to the individual's needs and wants, so no one specific device should or should not be used with ALS patients in general.

Submitted by,
Dawn M. DiPietro

Since we are discussing a case that involves a degenerative process, let's consider patient education.  It is a very touchy issue to discuss long range implications, yet many patients want/need to know what is ahead.  At what point do you think you should discuss the need for "things" or services that may be inevitable i.e. enteral feeding options, augmentative devices, direct care providers that take over ADLs?

Erin - You listed a goal for brushing teeth, washing upper body, and donning pants.  What about feeding, toileting, upper body dressing, and lower body bathing?  What about other grooming activities such as combing hair or washing face?
Also, some of your activities you chose for "maintaining" endurance are actually resistive exercises and I think would be contraindicated, e.g. the arm bike or the BTE.  I think it would be helpful to the patient to exercise in a gravity eliminated plane, so the rainbow arch could work if it wasn't high.  Other options would include wiping the table or pegboard.  It is CRITICAL however, not to fatigue the patient, and not to harbor any ideas about incresing strength.  Another option might be
exercising with the arms in a mobile arm support or overhead counterbalance sling. Professor Brenda Kennell

Could we talk a little bit about how OT and ST can work together to select AAC devices?  Specifically, what issues and solutions would OTs bring to our attention when selecting augmentative communication technologies? (Heather)

In Response to this question OT would bring to mind things such as The ROM of the client, the abililty of the client to use their head for a pointer, applying weights to reduce tremors of the hand.  The ability of the client to use a simple switch to
choose words or symbols.  Also we could adapt the area in which the communication device would be placed so
that it would allow for the most functional use for the client. (Frank)

When choosing an Aug. Com. device many issues would need to be considered and brain storming with another person/discipline would be most helpful.  Additionally, everyone brings experience to the table, both relating to disabilities and assistive device experience.  With the ever changing environment of assistive technology it is difficult at best to stay up-to-date with the latest tech. and therefore strength hopefully will be achieved in numbers.  I think some of the areas an OT
could contribute would be as follows:

• Cognitive abilities for using the device now and future developmental growth of the person and growth capabilities of the device (as we all know insurance companies are not lining up begging to be the one to buy such equipment)
• Physical abilities--can the person use their hands, arms, head, eyes, shoulders, neck, chin, cheek, toe, etc to trigger a device. This particular area can be broken down even further (in conjunction with cognitive skills) i.e.  the only functional movement a person has is eye blinks or tongue movement with cognition intact and able to manipulate a scan system with timers. Or sustained eye gaze therefore needing an infra-red (spelling ?) type system that detects eye gaze.
• Positioning--how versatile is the Aug. Com. device in meeting the person's needs in different settings?  In a wheelchair, in a tumble form, prone stander, using the bathroom or in bed.  Is the device structurally suitable for future adaptive attempts to accomodate the various aspects of communication needs in various settings/positions
• Maintenance of device, complexity or simplicity (teach families how to use and "trouble shoot" the device), turn around time when device needs repair and replacement options during these times, vendor support and follow-up issues, "inside scoop" of the reputation of devices, flexability of device to change when abilities change.
• Bring established relationships with vendor/s who can assist in getting devices, who's job it is and whom has experience in "knowing the loop holes/tricks" of the trade
• Knowledge of funding sources other than insurance and resources avaliable i.e. a family who has a particular device but no longer uses it and wants to donate such device.

In response to the question asked about augmentive communication devices- OT's can have a great impact on the type of communication device as well as were the device is located in relation to the pt.  When OT's assess the type of augmentive communcation device needed they look at several different things.  Among these are the pt's strength( in that how much
force the patient will have to apply to the device in order to activate it), the pt's AROM of not only the hand but of their wrist, elbow, shoulder, and also the flexibility and movement in their trunk because all of these things will impact were the device is located in relation to the patient.  We also must look at the pt coordination of gross and fine motor activities because this will impact how large the "button " needs to be in order for the pt. to be able to activate it easily.  Also with this the larger the buttons will take up more room on the communication board therefore limiting the number of commands the patient will have with one particular board.

Andy Powers

The patient is a 56 year old male who experienced a progressive weakening of his arms, hands and legs over two years.  Current complaints are characteristic of Amyotrophic Lateral Sclerosis (ALS), and include choking on foods, nasal
regurgitation, slurred speech, and progressive weakness of his upper extremities. Expected communication impairments
include a progressive loss of intelligibility due to reduced strength and ROM of the tongue, reduced rate, and abnormalities of voice, resonance and prosody.  Patient is at risk for aspiration at all stages of the swallow.  Expected ADL impairments include a progressive loss of ability to perform functional tasks and home management activities.

All assessments include a chart review and patient/family interview.  Due to the progressive nature of ALS, ongoing assessments are necessary.  Assessment of swallowing would include an interview, bedside evaluation and videofluroscopy if deemed necessary.  The communication assessment would focus on the subsystems of speech production, including: vital capacity, flow and pressure (respiration); s/z ratio (phonation); nasendoscopy and/or elicitation of reflexes and non-speech movements (resonation); oral motor exam (articulation); and perceptual rating of these subsystems as well as prosody
and intelligibility.  Assessment of basic and complex ADLs would include using the FIM scale to rate the patient’s strength, ROM, coordination, sensation, cognition and perception; assessment of endurance, and fine motor skills; and assessment of the patient’s overall ability to perform functional tasks and and home management activities. Prognosis is poor.  Rapid deterioration of motor skills affecting all aspects of life is expected, with a life expectancy of less than 5 years.

All therapies should include early education about the types of assistive techniques and devices that will likely be needed in various stages of the disease.  Strengthening exercises are not recommended for patients with ALS.  Swallowing targets would focus on compensating for the loss of muscle movement necessary to swallow safely. Activities include thinning the consistency of food, avoiding mixed food consistencies, thermal stimulation, and tucking the chin prior to swallowing.  Communication targets include compensating for the loss of muscle movement necessary to speak and communicate effectively.  Activities include environmental manipulations (speaking face to face and in small groups, away from noise),
establishing conversation topic/topic changes, developing strategies for resolving communication breakdowns (repetition,
rewording), and using augmentative communication.  ADL targets would focus on maintaining independence of ADL activities for as long as possible.  Activities include practicing adaptive techniques (pulling up pants while
laying down, writing with built up handles), exercising in a gravity eliminated plane (but avoiding fatiguing the patient), learning energy conservation and work simplification techniques, and using adaptive equipment.

Kathy McGraw