Many patients can benefit from co-treatment by speech-language pathologists and occupational therapists. In some complex cases collaboration is not optional but necessary for best practice and effective care.

Consider the case study of C.G., 55, who was diagnosed with severe brain injury as a result of anoxia secondary to drug overdose. Her acute hospital course was complicated by ventilator-dependent respiratory failure, aspiration pneumonia, tracheostomy, percutaneous endoscopic gastrostomy (PEG) placement, line infection/sepsis and urinary tract infection. She gradually was weaned off ventilator dependency. 

Once medically stable, C.G. was admitted to the Severe Disorders of Consciousness (SDOC) program at Kessler Institute for Rehabilitation, in West Orange, NJ, for daily speech, occupational and physical therapy. She was considered to be in a vegetative state because she did not respond to multisensory stimulation, demonstrate purposeful movement or functional object use, or follow simple one-step commands. She presented with a combination of hypotonia and spasticity throughout her body, including flaccidity in her neck.

C.G. had no functional communication system and received all nutrition and hydration via PEG tube. She could open her eyes inconsistently but had poor sustained arousal. Vestibular and other therapeutic stimulation was provided for increased arousal.

She did not demonstrate a visual or auditory startle response and could not follow simple commands. She did not localize to sounds in her environment and was unable to fixate visually on or track objects or people. Her motor movement was limited to flexion withdrawal. Oral reflexive movement was present.

Therapy included sitting balance training and neurological re-education of body positioning in space to enhance levels of arousal, visual attention, auditory localization and upright sitting capability. The OT provided posterior support to the head, neck and trunk muscles to achieve stability and used mirror techniques to provide visual feedback for improved attention, visual fixation, and awareness of body positioning in space. The most successful treatments were manual stretching, splinting, and facilitating optimal positioning.

C.G. was unable to maintain an upright, symmetrical posture in a bed or wheelchair. Her poor positioning due to spasticity put her at risk for aspiration during essential dysphagia therapy. Co-treatment was necessary to continue addressing her dysphagia goals safely.

C.G. was able to approximate the ideal sitting position with assistance from the OT. This symmetrical posture aligned the shoulders over the pelvis. The knees were at a right angle of flexion, and the lower extremities were weight bearing on the floor surface. Model positioning was obtained through the use of equipment, such as bolster cushions and positioning belts, and manual assistance.

Dysphagia therapy focused on triggering consistent and multiple swallows with the use of oral stimulation. Cold lemon-glycerin swabs were rubbed on the posterior lingual surface, facial arches and posterior pharyngeal wall to enhance a rapid swallow response. Following rigorous oral care, therapeutic ice chip trials were provided. An ongoing assessment of C.G.'s arousal and response to multimodal stimulation was conducted. 

Positioning barriers with complex patients like C.G. can be eliminated during speech therapy sessions through co-treatment with occupational therapists, who can achieve optimal seating and head and neck support. Appropriate positioning makes the achievement of various goals possible.

Collaboration can help maximize patient performance and outcomes in order to achieve discipline-specific goals. This provides patients with the opportunity to enhance functioning and optimize progress.

Resources

• Berube, J., Fins, J., Giacino, J., et al. (2006). The Mohonk Report: A report to Congress. Disorders of consciousness: assessment, treatment and research needs. Retrieved from www.northeastcenter.com.

• Giacino, J., Whyte, J. (2005). The vegetative and minimally conscious states. Journal of Head Trauma Rehabilitation, 20: 31-50.

Madeline Kraemer and Anita Joy are on staff at Kessler Institute for Rehabilitation. They can be contacted at mmkraemer@selectmedicalcorp.com and ajoy@selectmedicalcorp.com.