0:00

EPISODE 22 [INTRODUCTION] [0:00:04.5] ANNOUNCER: Welcome to Brainstorm[s]: Functional Neuro Rehab for SLPs, presented by SpeechTherapyPD.com. This podcast is designed for the adult medical speech-language pathologist. Most of our audience members work in settings such as acute care hospitals, private practice, outpatient hospital clinics, and inpatient rehabilitation hospitals. Each episode has an accompanying audio course on SpeechTherapyPD.com and is available for 0.1 ASHA CEUs. [DISCLAIMER] [0:00:42] ANNOUNCER: The content of this course is based on the research and experience of the presenters. The listener is responsible for researching to determine if the information and skills taught are appropriate for their clients, students, or patients. SpeechTherapyPD.com does not necessarily endorse, recommend, or favor the information shared, nor any of the claims, opinions, statements, offers, or services made by the presenter. [INTERVIEW] [0:01:07] RG: Hello, and welcome, everyone. My name is Renee Garrett, and I'm your SpeechTherapyPD.com podcast host for Brainstorm[s]: Functional Neuro Rehab for SLPs. Before we get started, we have a few items to alert you to. Each episode is 60 minutes and will be offered for 0.1 ASHA CEUs. Here are the financial and nonfinancial disclosures. Fred Stal receives an honorarium for his appearance on this podcast from SpeechTherapyPD.com and he has no relevant, nonfinancial relationships to disclose. Renee Garrett is a paid employee of a private consulting firm in the Commonwealth of Virginia and she, as the host of Brainstorm[s]: Functional Rehab for SLPs, receives financial reimbursement from SpeechTherapyPD.com. She also receives financial compensation for this and other webinars on SpeechTherapyPD.com. She is also an adjunct instructor for both James Madison University and Old Dominion University. Renee is the current secretary for the Communication Disorders Foundation of Virginia. Now, without further ado, we welcome our guest, Fred Stal. Fred Stal is a certified speech-language pathologist working in New York City in the greater New York City area. His initial training began at the Cleveland Clinic Rehabilitation Hospital, where he completed his CF. He currently works in the outpatient setting, part-time, and per diem in the acute care setting. His clinical focus includes voice and swallow disorders, including working with the head and neck cancer population. He recently collaborated with the New York University Swallowing Lab on novel research on modified barium swallow exams, Bolus measurement, Bolus clearance ratio, and related objective swallow parameters. He is interested in gaining additional experience as a clinician and research in both of these areas. Welcome Fred, thank you so much for joining us. [0:03:09.8] FS: Thank you so much for having me, Renee, it’s a pleasure to be here tonight with all of you. [0:03:13.7] RG: Yeah, it’s great to see you, it’s been a couple of months. [0:03:17.0] FS: Yeah. [0:03:18.4] RG: I think we’ve all been quite busy. [0:03:20.6] FS: Always busy, yeah. Getting a break is nice, it’s a rare treat. It’s part of the life we choose, right? [0:03:29.0] RG: Yeah, yeah, the passion spark and what’s the theme? Ignite? Last year, elevate. This year, I think that’s pretty much the standard for career goals. So, let’s kind of just jump right in and – [0:03:41.3] FS: Sure. [0:03:41.6] RG: What would you say, really kind of – and I say this because my background is also in acute care and I spent a long time working with dysphagia and different reasons for dysphagia for the patients and so, I still don’t consider myself an expert by any means. My background, like the area of expertise that I’m certified in, is brain injury but talk to us about what sparked your interest in heading that cancer. [0:04:06.9] FS: Sure, it’s really a very long story. [0:04:09.0] RG: Oh good, I like the long. [0:04:09.7] FS: The short of it, doing a semester in the hospital setting as a grad student, I realized there is a certain spark within me. Just being in there, I felt like just a different part of me, this passion that I didn't have with some of my other clinical rotations and I had a great supervisor and a whole team of medical SLPs. So, it was just that nice kind of team spirit if you will, like a lot of support. I was never afraid to ask questions and I had gone to one of the managers there. I took a diagnostics course with her and she was kind of like the lead SLP for that team, and I was interested in learning more about objective swallow studies and I like, had no idea this is even a thing that I could do video for fluoroscopy, FEES, and so she suggested to me to email Dr. Eric Blicker, actually. So, I emailed him like, “You know, I’m interested in volunteering.” I already took a basic FEES course with the great Queen Susan Langmore, Dr. Langmore is like, my favorite, one of my favorites. So, I went and basically, it was the nose. You know, people scoped me, and just being there and getting some passes and getting scoped on, it really, not only like, helped me feel like the patient, you know like we’re scoping and doing all these things. But I just learned a lot, absorbed a lot, being in that environment and I met a friend and mentor, Lory [Wonderhall 0:05:29.1]. You know, she's currently going through her Ph.D. through the University of Queensland and she's a real head-and-neck expert, I would say. I think, the great ones are very humble and say they're not experts, right? But she took me on as a mentee. I did a mentorship with her and I just found that we had a very pivotal, unique role as SLPs working with head and neck patients. I think, other than obviously, surviving disease, the next priority was quality of life and that is a big part of that eating and drinking again and just you know, not only giving the patients a voice again with like the eTEP patients, our total laryngectomy patients but how are these people going to even drink again, and I think it takes a lot of knowledge to not so much take away from those patients but give them somewhat of a life back. It’s a very big new normal to take on after radiation, chemo, in some cases, surgery, chemo, and radiation, you know, triple modality treatments. It’s quite a lot to go through. If you ask any oncologist or oncology nurse, they’ll tell you that head and neck treatment is by far, the worst cancer treatment to go through, given the head and neck regenerates. So, it really was one thing that led to another, that led to another, that led me to meet these great people, who kind of took me on and I got some really good mentorship. So, I’d say, really through Lory and then learning about MD Anderson and really big Dr. Kate Hutcheson fan as well, you know, and just her work, it’s been kind of like an ongoing journey from there. The more I learn about it, the more I love it, and it just ignites more passion and interest in learning more. So, that was the initial kind of what sparked my interest in that was just being at the FEES course and learning so much by just talking with really brilliant people. [0:07:10.1] RG: Yeah, no, that’s great. I’m kind of thinking on my feet here right now because I think for me, it’s such a nuanced thing because there aren’t a lot. I don’t feel like there’s a ton of people when it comes to just speech-language pathologists who necessarily specialize in this and maybe I’m wrong. I just haven’t come across a ton of people who focus solely on head and neck cancer. It’s usually more of a – like a niche, right? So, like for our health system here, we have basically one or two people who really focused on the - like you mentioned - all these other aspects, like voice and TEP and total laryngectomy, swallowing, all those things, and then the other health system that’s nearby me, same thing. It’s been the same person for a number of years and there will be people who come in and are interested in and maybe do like, their CF or maybe they do their early career first couple of years and then they move on to somewhere else and we’re still with the same one person. So, where you're at now, is there like a – still a team of SLPs that are serving in his head and neck cancer population or is it just one or two folks? [0:08:18.4] FS: It’s a couple of us. It’s one in particular, a woman named Lisa, I’m working with, out of Atlantic Health, you know? So, I’ve been with Lory for a little bit. My AQ care job, we will get some head and neck cancer patients that come in but really, it's through the outpatient setting where I'm working in New Jersey, where I do get a lot of head and neck patients that come in, and their go-to person who I’ve been working closely with over the last year is Lisa DeMasi. She had been 20 plus years a head and neck specialist. So, she knows so much about the lymphedema aspect of it. She did take the course but I think what happens is, we get so gung ho and we take so many courses, we sometimes forget to apply all the knowledge we learned and you know, it’s a lot of other aspects to look at and I think, really, the last two, there, four years specifically, with some of the research, we’re realizing more and more how lymphedema, not just what we can see on the outside but the internal lymphedema. Through what that research has shown, plays such a pivotal role in functional outcomes. So, initially, it was all radiation fibrosis, which I think is such a big underpinning. Just those complications, you know, late radiation toxicity. You know, you’re essentially getting cancer burned out of your tissue, and with that comes, you know, it’s a different tissue afterward, and again, hopefully, you survive that treatment. But a lot of rigidity, a lot of loss of range of motion, your ability to even just turn your head over time gets impacted. So, a missing link to that treatment paradigm and I think it speaks to the importance of multi-disciplinary collaboration is the lymphedema stuff, you know? Managing the external part but even for patients that don’t manifest with real external edema, they still have voice changes. They have internal swelling and then there is fluid within the lymphatics, which you know, I'll get into a little bit but that kind of has nowhere to go. It’s supposed to sort of flow throughout your body and that can hurt over time as well. So, learning how to manually move that fluid and educate the patients on compression is something we’ve been doing more and more of, which I had learned through some of my colleagues at NYU and through Lory. You know, Lory and I had done the Head and Neck Norton Course last January in Portland. So, it was a very intensive course and from what I hear, the CLT course, which eventually like, I probably will take and become a certified lymphedema therapist is even that much more grueling but you know, there’s just always so much to learn. It’s quite complex and overwhelming to think about. So I, you know, when you sort of look at the nuts and bolts of it. You know, skincare, managing, you know, you have disclamation, you have desquamating, it’s like a sunburn to the skin, managing the skincare, educating about compression and why it’s important to wear compression to retain that fluid so it doesn’t build up and get worse, and then manually draining that fluid through MLD, manual lymphatic drainage. So, it’s been a nice kind of teaming up, if you will, with me and Lisa. A veteran head and neck specialist, she does a lot of the eTEP fittings and then there’s a lot of dysphagia therapy. It’s a lot of education and it’s pointing those patients to the proper resources, social work, the mental health aspect of it that again, I think there’s just so much there that you want to know who to refer out to because we can’t do everything. You know, sometimes SLPs are expected to, we just can’t do everything. So, it’s been a nice team for sure but a small team right now. [0:11:38.2] RG: Yeah. So, I’m going to backtrack a little bit because you just brought up a lot of excellent points that hopefully I remember to get back to because I think there’s details amongst all of those things. So, if I get lost, I’m counting on you to bring me back. [0:11:52.6] FS: Please, and likewise. [0:11:54.7] RG: So, we’ll start from the beginning I guess is a good way to go, is assessment, you know? So we, like, for me, when I would get someone with head and neck cancer, it was a two-fold thing. So, when I worked in acute care, typically, I would get them for modified barium swallow like a snapshot in time. As an outpatient, it was a one-shot deal. Sometimes people would come back three to six months later for a repeat. And then, when I worked in outpatient, I would get patients who typically would have late-term radiation effects that impacted their swallowing and sometimes voice, more so swallowing was the bigger concern but I’m talking like, 10 years post radiation. So, it wasn’t something where I was getting these patients with like acutely done with their treatment. It was like, the late-term effects. So, let's talk about assessment. Where do you start with this group? [0:12:49.5] FS: Sure. Well, I guess some of the first questions other than doing a new chart review is, “Have you been eating at all? Are you completely NPO? If so, what have you been eating? Is eating and drinking a goal of yours?” Just starting with that. Those have been some tough cases, some people are afraid to eat again or told that they never could, and so I think there’s a lot of education just on that alone, let alone clinical assessment and just looking at range of motion. You know, is this a real late rad case, you know, real late rad toxicity? Do they have a swallow function at all? I think an objective assessment is so useful but I also believe that clinical swallow exam is too. You know, there’s so much we can infer that needs to get figured out even before the objective assessment and be asked these. So yeah, I would usually start with that. Like, “How can we help you? Is eating and drinking something that you would like?” “Have you had anything? When is the last time you’ve had a meal?” And I would look at max phonation time. I also look – I like to look at cough strength. I think other than swallow function, I love a lot of the work out of you know, the upper airway lab at Columbia and shout out to my New York people, you know? We learn so much about swallow, swallow, swallow but like you know, there are patients who aspirate and will aspirate for the rest of their lives who never end up with an aspiration pneumonia. So, cough strength I think is very important in how I see through my clinical lens, and also I love digest. You know, through MD Anderson, again, great work. I was just talking about this at DRS, like, swallow safety which we talked a lot about aspiration but also efficiency of swallow. A lot of patients you know, really, the underpinning of their impairment is the efficiency of their swallow, which then can affect the safety of their swallow as well. So, I think about those things too. Can they move food from mouth to stomach efficiently? And obviously, aspiration as well. I’d say, a big benefit of being in the acute care setting is I have access immediately to lab work. I look at the CBC differential, I like to see white blood cells, I like to look at neutrophils, you know, that tells me something about their infection risk and again, you know, pillars of aspiration pneumonia, Langmore, that research. So, it’s really calculating their risk, looking at how strong their cough may or may not be. I started in inpatient rehab and what I like that we did, we used peak floor meters, which are relatively cheap and – [0:15:14.9] RG: Yeah. [0:15:15.4] FS: And I looked at some literature in pulmonology and I’d like to see more literature within our field. We have some great stuff out there. You know, what’s the volume that they can expirate out and if it’s relatively – if it’s under 200, you know, we’re more concerned that that could increase their risk, give or take. Between two to 300, moderate risk but you know, if they’re in that 28 and above category, correct me if I’m wrong, I’ll have to look again at the literature but that’s more or less in my mind what I’m thinking of, that’s telling me if they do aspirate, they can protect the airwave. [0:15:44.7] RG: Yeah. [0:15:44.9] FS: I think that’s – [0:15:46.1] RG: And yeah, we talk about that a lot, or at least, I have recently because I think for so long, we were so stuck on aspiration. Aspiration, aspiration but you know, we weren’t necessarily talking about how again like you mentioned, we have patients with head and cancer who chronically aspirate over their lifespan and they never develop aspiration pneumonia. So, who are we to be the diet police and say, “Absolutely not, you’re not allowed to eat or drink because we saw this little tiny millimeter of a particle go down into your airway that you were then able to cough” right? Cough strength, cough, cough it out, swallow again, and clear it out. So, I think that’s a great, great point. I know I’ve seen that many, many times on those outpatient modified barium swallows who came in again to see me for a one-shot deal. Then, on the flipside, when I went to outpatient and I would send my patients over because the facility I was at was new, newer, new-ish, and wouldn’t – they didn’t have the capability yet for me to do my own swallow disturbing nuts because I trained all the other people for the most part. So, it’s like, “Come on, just let me do the thing.” But I would send them over and they would have this like, one little tiny microaspiration or you know, very minimal on the first swallow, took too big of a sip or whatever it was and it may not even – We don’t even really know objectively what happened, it’s just they aspirated on the first sip, the radiologist freaking out, and the speech-language pathologist said, “You know, take another sip” and you never saw them aspirate again but then they want to make diet recommendations for neck or fit because that looked better and then when I go in and I look at it, it’s like, but they had so much residue with the thickened liquids that they were unable to clear. And I feel like we’re just in this like, catch-22 all the time, depending on who is doing the study, whose got the – I won’t even say experience because that’s not a valid statement. I know I’ve seen people with a ton of experience who are operating in this old sell mode of thinking who would make that person NPO or automatically less to honey thick liquids or everybody gets a chin tuck, everybody gets a head tilt, and just – it’s incredibly frustrating. [0:18:00.0] FS: So frustrating. You know, I’ve had to really like, advocate for myself, especially as a very new clinician, I’m still relatively new, for training and you know, I’ve heard some people say, “Listen, I would love to train you because I don’t have to untrain you.” And I think we’ve had to come a long way in terms of coming from a place of research and informed decision-making and educating our patients, rather than a place of fear, where we’re just taking things away from people that are so important to life, literally. So yeah, I hear that, for sure. It can be frustrating but I think, it’s important to have those conversations, you know, rather than like a shame on you, like, there’s this fear of, “Am I doing it the right way?” I think, coming from a place of humility, something I have to remind myself of and to know, you know, people with years of experience. That’s why, you know, the person I work with closely with now, like, if she wants to learn, she’s always learning and I don’t want to ever lose that. It is a scary thing when you're dealing with the airway when you’re making decisions. Like, my first day, like, on my own at acute care, doctors were asking me, “Can this person be PO?” and that’s a big decision to make. So, I can feel confident, I can – a lot of pressure? [0:19:08.4] RG: Yeah. [0:19:08.6] FS: And I think people are afraid of that hypothetical scenario in their mind, what would you do if you’re in this courtroom and you can’t see them again? I don't know many people who are – that’s happened to them. I had a talk with [Karen Sheffner 0:19:19.4], you know, she’s doing some legal consultations. So, there’s so many different avenues to take as SLPs. But I think if you’re documenting well and really being transparent and you practice and what’s going on, you know, I just think we can make really good decisions that aren’t limiting but also protecting ourselves. But I know for me, I don’t want to ever be that clinician that’s coming from a place of fear and making the wrong choices for what my patient truly wants and hopefully would be able to do. [0:19:45.0] RG: Yeah. [0:19:45.4] FS: With eat and drink, you know? [0:19:47.4] RG: Well, and I think too when you look at the – like you said, the shared decision making, we have a responsibility to provide all of the avenues and what that education piece looks like as far as risk but also respecting. I mean, I know I’ve had patients who were like, “I don’t care. Like this, I’ve been through the worse.” So, you know, like you mentioned the triad of modalities of surgery, radiation, chemo, I’ve been through that. I have this now and if I want to eat a crab cake on a Friday night with my spouse or my grandkids or whoever it is they want to hang out with, yeah. My last really big case that I had, he was coming to me and we were doing swallowing exercises but they were talking about pulling out his – he had been pegged tubed dependent for about a year because he had some complications when he completed radiation. He was having some bleeding in his oral cavity and lots of, of course, xerostomia and that kind of stuff but he had pretty significant lymphedema and he actually went to PT for the management with that, and then just a lot of medical complications that he had but what he started doing on his own because it was taken so long for his physicians to respond whenever we put in order request for modified barium swallow. He started saying, “You know what? I haven’t been sick in a while, I never had aspiration pneumonia, I’ve never had pneumonia at all.” And he was in his 70s. He’s like, “I’m going to see what I can do.” And then he would see what he could do and he’d tell me about it afterwards because I think he was afraid I would kind of be like, “No, you cannot do that.” But he came in and he’s like, “Hey, I got to tell you something, I had scrambled eggs this weekend.” And I’m like, “Okay. Well, how did it go? How did you feel? What were some challenges for you or do you feel like it went great?” So, he was able to kind of describe that he felt like it was stuck. We knew that he had vallecular residue from previous swallow studies and for a full swallow, double swallow wasn’t effective for him but he would say, “Well, if I clear my throat and then I swallow, I feel like I can clear it up.” And the other thing, the big thing for him was he would say, “If I take too big of a bite and I don’t chew it well.” And I said, “But that’s for everybody, right?” He kind of would chuckle and he had a really great sense of humor and so, I wasn’t going to ever tell him, “Don’t do that” because he was fine. He was doing great and my biggest thing for him when you’re thinking about barriers was I didn’t want for him to go to the doctor. And they pulled the peg tube out before we had the repeat instrumental in case there was something really catastrophic that could put him in a, you know, danger of airway obstruction. His cough was actually freaking great for lack of a more confessional term. I mean – [0:22:33.8] FS: There you go. [0:22:34.6] RG: Yeah, and he had been working with EMST, the strength trainer at home for a little bit. So, yeah, but just thinking about like barriers for treatment, I think that’s a really – when we think about our head in that cancer population, a lot of times, it is medical complexities and complications that occur as a result of the treatment. So, can you talk a little bit about that? [0:22:58.9] FS: Just the medical complexities in general? [0:23:01.1] RG: Or just some of the things that could happen as a result of chemo and radiation, sort of in that immediate post-treatment phase. [0:23:09.9] FS: Yeah. So, generally, patients that I’ve worked with, there is more oropharyngeal cancers, you know, above the larynx. We’re thinking base of tongue, even though we need that for swallow efficiency and really swallow in general. It’s like the power driver of your swallow. There comes a point where counseling needs to happen. Ideally, we want to get someone in before they even start radiation. We want to teach them the standard head and neck range of motion, effort-pulled swallows, just getting them acclimated to what, like, prophylactic exercises really look like as far as dysphagia goes and then, I’m a really big fan of head and neck cancer support groups. I know sometimes, that can scare people at first but you know, they really need each other and I think that value of them helping each other be like, “I have literally been through this too.” Is so crucial. So, that would be the most ideal situation. Not everyone’s completely on board right away and honestly, they’re just overwhelmed with the treatment they have to undergo and there is a cumulative aspect to radiation. In the first week or two, not too bad. The last couple of weeks, once you’re about midway, that cumulative effect really starts to hit you and you feel like you can’t make it through. And I think that’s when you really need to be there as an emotional support and that’s usually where you have such pain when swallowing because of that treatment that at that point then, you know, alternate means of nutrition and hydration are warranted and then you would counsel them. “Well, this isn’t a forever thing but it’s, you know, we’re going to try to get you back to swallowing as soon as we can.” Because we know from research, definitive, good, solid research, the sooner we start doing it and at first, it’s going to suck for lack of a better term but you have to sort of suck it up and do it so that it will be easier later. The you, in a year from now, will really thank you now, for you know, sticking it through and it can be tough and the other thing too is just the dyschezia. You know, there’s a change in the PH in your mouth. You know, there’s a lot of talk in the scientific literature about the gut microbiome, we have a microbiome in our mouth too, it’s all really one continuum and you know, as the PH changes, the taste changes too in a lot of people will find things, especially that are acidic are like rough. Like I’ve worked with some really tough guys who are head and neck cancer survivors, who thought that they could have a cup of orange juice and thought they had to go to the hospital because it was so, just raw and painful to have anything with any acidic quality to it. So, those are some of the challenges I think. This really is hard, I don’t feel like I’m going to make it through and food and liquids just don’t even taste that good anymore and that’s when somebody who has been through it, who is a year or two out or more who can say – you know, because they might not believe me but you will get some taste back. In fact, you might get a lot of taste back and it’s sort of that motivation to really push through, especially when you need to really push through. It’s very hard but that vigilance is so important. So, those are some of the complexities because who wants to be punted around to the specialist and that specialist and it’s a lot, you know? And I think there can be a lot of just exhaustion going to so many appointments for so long, and so I try to keep that in mind too. You know, we want to save the world and do it all and like I said, referring out is so important. But really, giving that education and preparing them in a way that’s hopefully not going to scare them too much but prepare them mentally and emotionally so they can get through it. These are some of the things that are as important as the clinical interventions. [0:26:37.7] RG: Yeah, no, I think that’s great. So, you know, psychological barriers, pain barriers, sensation change barriers, and then fatigue, like you mentioned, activity tolerance because it is exhausting too, not only the going from appointment to appointment but just the treatment in and of itself is physically exhausting and also, mentally exhausting. So, I think those are all really great points because yeah, you know, I’m thinking about a couple of the patients I saw back, right before the holidays, and for them being able to come because there was one guy that was going to treatment five days a week, and then for him to be able to – and I’m being pushed, you know, from a productivity standpoint to have him come two or three times a week. It wasn’t, it’s not feasible. He couldn’t physically do it and you know, there was a transpiration barrier because they were coming from a city a little bit further away. It’s about a 40-minute drive one way and then he started with like, nausea in the car and you know, the pain was there like you mentioned, and it’s – there’s a lot to be said for having that supportive network behind you that may or may not be like your immediate family and friends who aren’t necessarily going to understand what you’re going through. And we know that the literature supports support groups for a lot of different populations but specifically for this population and so, I think those were all really great points that you made, and thinking about the patients that I have seen who – because I’m not lymphedema trained and so, typically what I would do, like again, you mentioned is, refer to someone else because I can do the swallow piece of it and the voice piece of it. But I cannot do lymphedema management. I’m not trained in it, not certified in it so I never felt comfortable or confident in portraying anything but other than that, and again, that’s one of those things where there’s nothing wrong with saying that. You need to refer. If it’s not for you and you don’t have the capabilities of doing that, we’re ethically responsible to refer. [0:28:34.9] FS: Sure. [0:28:35.5] RG: So, I kind of want to jump into that and just the lymphedema management without you know, you can be as technical as you’re comfortable being but I don’t want people to think that then, they can go back and say, “Oh, well, I heard about this lymphatic drainage and now, I’m going to try it.” Don’t try it. Don’t try it without the appropriate training. [0:28:55.6] FS: Yeah, I think for me, the hardest thing because I’m thinking, manual therapy. I took a great course and then I love massage, personally. This is like, all about a very gentle tug to open up these filaments of the lymphatic system to allow the fluid to move. So, it’s a very specific sequence and it’s a very specific level of pressure. So, definitely, don’t try this just yet until you really get trained and we did spend a lot of hands-on time. You know, we learned through Christina Porsche, who is absolutely amazing. She’s also out in MD Anderson and they had an OT come in and help and something that the OT said and I just love being able to collaborate with other disciplines, she said, “Don’t ever discount yourselves because really, we are the swallowing experts. You know we should be.” And I think that it’s easier to feel like our scope of practice is one thing when really, I think it’s still evolving. I think as a field, we are actually still an embryo. I don’t even think we are, to quote someone else who said that but it’s the baby stage, but really, the embryo stage. So, that being said, part of the swallowing intervention paradigm should involve us doing lymphedema therapy, especially for these patients. And we do have a lymphedema unit where I work and we have PTs and it’s been really great but I will spend time. You know, when someone recently had some patients who have had their peg removed, their eating, I’m working with them, they’ve got a good handle on what their home exercise plan is. We’ll work on trismus, which I really didn’t get too into but that’s you know, an ability to really open their mouth to be able to eat, and again, this is an effect of the cancer treatment itself. So, using devices, whether it’s a thorough bite or a stretch, passive jaw range of motion, there’s so many different things we could do within with that devices, but it's important to do all of it and for us to own our role so we can refer out but to not be afraid to learn new tools that we can do and I absolutely believe, we should be managing lymphedema as well, especially for, not so much for mobility. But the head and the neck and eating and drinking specifically as well as voice because that internal edema also will affect vocal quality. So, I think there is some good research out there. We should look more at voice and swallowing and how that can change before and after, you know, treatment of the lymphatics in addition to your standard swallowing protocol. So, there is the manual lymphatic drainage and it can all feel very overwhelming but what I like about outpatient is I’ve been able to work. Like, there is one gentleman in particular, it took four or five months. He thought he would never get a pec taken out and it was taken out in December, and then we just were able to just focus on manual lymphatic drainage and trismus and he’s doing great and it’s a complex case because there’s other factors. There is, you know, he did end up with infections and aspiration pneumonia. These are the types of cases where you know, I think it will scare any clinician but oral care, just brushing your teeth, don’t ever underestimate the most simple things, that can go such a long way. So yeah, these are all things for us to think about and I don’t think any of us, maybe some of us learned the proper tools in graduate school but I had to seek the mentorship and be a total nerd and read research and ask questions. And be willing to look at them so that I can really learn because you know, I think the more you know, the more you realize you don’t know. So, there is just so many aspects to think about. [0:32:21.5] RG: Right, and I think it was Dr. Ashford that was telling me that and I think it’s the UK, they’re actually, they have a newer evolving profession where it’s not a dental hygienist but it is someone who’s trained as a – I forget what the terminology is exactly but they’re basically were trained to do oral care within different settings like acute care and that’s what their job will be, just like we – and this was before your time. But it used to in acute care, they had phlebotomists and their job was to draw blood like that was their specialty, and I worked with someone who - she was certified within the state to that was what she did. That's all she did all day long and I mean, you could go behind her after she was done and there was not a mark on that patient's arm. I mean, she was great. [0:33:08.7] FS: Wow. [0:33:09.4] RG: Like, fantastic at her job and like train that’s her – that was her life’s work. I don’t know about you but when I go for lab work, I’m not really afraid of needles but I’m afraid I walk in and I want go, “Oh no, that person, this is not going to go well. They don’t look like – I saw that old guy that came out. His arm looked like crap.” And so – [0:33:30.0] FS: Yeah. [0:33:30.6] RG: You know? To think that they’re – it could be someone potentially who is specifically trained in oral care and that’s their role specifically in a hospital setting would be fantastic. We all – I love nurses, most of them don’t have time and they hate oral care as far as performing it. I laughed not too long ago because OTs, they have no problem with like cleaning up a bowel movement. But they do not want to get in anybody’s mouth with a toothbrush and I’m like, the opposite is true for me. I will – I made a joke not too long ago about that during the pandemic with all our gear, when we had all these layers of masking and stuff, I was like, “Yeah, I can get those dentures clean, no problem” because I can’t smell them because there’s nothing worse than you get called down to the ED and it’s like these dentures that have been sitting in someone’s mouth at the nursing home for months, and you pull them out and you’re just like, “Ugh.” I don’t want to dial this bill. [0:34:25.3] FS: The work, yeah. Yeah. [0:34:27.8] RG: But it’s so necessary because we have, like you said, there’s so much literature in everything else to review that per – we don’t really have to review it. We just know that the literature is there that says oral care is paramount and so many different disease processes in preventing future problems and issues but particularly for our head and neck cancer patients. The one thing I think you mentioned too about counseling, a lot of the time what I’ve seen with patients who maybe have core dentition or have some infection present or even like cavities, tell me what they do to the patients before they start their treatment because I think this is not widely known unless you work with this population. [0:35:09.5] FS: Oh, absolutely. Again, it’s like the most simple things that go a long way. I think it was last year, it was my first DRS and there is so much talk about the clinical profile of these patients and really sciencey stuff, regression analysis, you know, research design, all the different medical subsystems, and then Dr. Langmore comes up and she says, “Well, I hope you have considered brushing the patient’s teeth.” And like walked back to her seat and it was so brilliant and so true and again, if I only had a dollar for every time I’ve had the discussion just about when a patient will say, “I do brush my teeth” but they really miss up their dentures and there is just a lot of debris and a lot of bacteria in there oral cavity, nope, soak your dentures but there is a whole lot of surface space here that needs to be cleaned and multiple times a day. Just positioning yourself upright, cleaning your mouth, working to fatigue, swallowing, you know, getting those muscles going can work wonders, very, very simple stuff. [0:36:08.8] RG: Yeah, because what happens is that before they have any kind of chemoradiation, a lot of times what the surgeon will have done is removal of the teeth that are remaining. I mean, I am sure you’ve seen that, right? Where they go in before their treatment and someone who doesn’t have good oral care and they’ll take – like they’ll remove the teeth that are remaining prior to their treatment. And I don’t know if that is just unique to my area because it is more rural but I’ve seen that at times and that’s – you talk about that’s like devastating because that takes a long time to heal and if you’re jumping somebody right into chemo and radiation, where we know tissue’s going to be impacted, that’s going to be a challenge for that tissue to remain intact and so then you start looking at things like deterioration of gum tissue but also bone. [0:36:58.7] FS: Correct, and there’s also the chance of osteoradionecrosis, another [inaudible 0:37:03.6] that again, go into some of the head and neck summits. We’ll talk with you know, oral surgeons, dentists who are on par with us and so you know, I think unless you speak that language and think about that, these are things that might not even get considered because again, they’re – especially nowadays, only so much time to do your job as a healthcare professional and we’re sort of thinking in a silo. And so specialized that we’re not zooming out and looking at the bigger picture. That includes oral health and possible complications like what you just mentioned, that’s a very good point. I know some places will protect the mouth with dental guards but other places that some big names that don’t for whatever reason. So, I’m wondering is that something to look into, can we standardize care to protect oral cavity more? That’s a very good point. [0:37:50.0] RG: Yeah, and when you think about like the osteonecrosis, can you talk a little bit about that and what the risks are to the patient other than just the death of the tissue, more thinking about bone structure? [0:38:02.0] FS: Yeah, so that’s an infection that can actually cause other complications, possibly death, heart problems. You know, there’s a link, you know whatever is in the periphery is in other parts of your body as well and so, this is not something – it’s not just like, “Okay, from an aesthetic point of view not having your teeth or having things not be quite how you want them to be.” But really, it’s very important for overall health as well and it’s one of those things that while it can be rare, it’s still a possibility and you know, for those patients who’ve had a history of oral health problems, who’ve had teeth removed, who maybe have certain exposure in their gums, you know, that’s something to consider. That should be discussed with the oncology team prior to treatment for sure because there’s, you know, you have to stratify risks and figure out who is more at risk of this kind of complications. [0:38:54.9] RG: Yeah, and one of the people that I had, he wound up having just his jaw is so demineralized that he wound up having a fracture in the mandible and it was just related to the treatment. There was nothing that happened, there was no trauma, there was no fall, nothing like that. It was just strictly – and we had to put a pause on the range of motion exercises because not only was it painful. But now, we have this mandibular fracture that we can’t really work on range of motion for the jaw when he’s got to heal this fracture that’s yeah. [0:39:30.6] FS: Yeah, and that speaks to the importance of like these are complex patients and you know, I think some of the opportunities out there it’s like having the right mentorship is so important because you know, who’s going to be trained to even think about that, you know? That’s why clinical experience is so important, like what you just described, yeah, that can happen and it’s like, “Oh, I was planning on working on this but we got that to deal with instead.” And it does happen for sure, especially with this patient population. You know, you want to get in there and save the world and get the range of motion exercises and you have sort of your plan, you know? But the idea of like, heuristics and clinical bias like there’s other factors that we have to think about. I think the more you realize there’s room for a complete left turn with something like what you just described, it will help you be more prepared because you just never know. [0:40:21.9] RG: Yeah. So, let’s jump back to lymphedema management because you mentioned going to training, you mentioned sort of all this co – like I don’t have support. It’s not really a cotreat but like observation, mentorship with physical therapy too. So, how do you kind of determine who does the lymphedema management, or does your system kind of utilize both? As far as – [0:40:47.9] FS: So, the system utilizes both. I wish, you know, more places had a lymphedema floor and we do have it. I’m trusted with my coworkers and my manager but I think you know, some SLPs would rather refer out because we can, whereas for me, you know, I brought some of these articles here just we see so much more how speech pathology particularly, like we want to look at the whole picture. And part of the clinical assessment other than you know, back to your original question too, if there is external lymphedema and there is a clinical profile where like you know, they are clearly – they have lymphedema, we want to get in there and get measurements beforehand, you know, measurements of their head and neck. It can usually – I am seeing a lot in the jowl region and you know, we’ll measure their entire head and neck and write down those measurements. And that is part of the protocol that I was taught and a lot of education and then we go in there and other than the swallowing therapy, we’ll get in there immediately. We’ll have them get you know, head compression. You know, there’s this JoVi wraps, there’s Epstein garment, you know? And there’s ways to even make stuff on your own and what I loved about our instructor like, by being crafty. I mean, you know, people don’t want to spend another USD 200 in some wrap after that, some financially toxic, let alone radiation toxicity is toxic just financially going through this type of thing. So, looking at what kind of edema it is. So, again, our lymph system, the lymphatics, it’s tied to our immune system. Think of it as like a filtration system within the body, we have fluid that carries these immune fighting cells. That fluid if it’s zapped with radiation or the other thing too is that cancer does travel, it can metastasize through the lymph nodes. So, it’s these little bean-shaped cells, it creates some sort of dam effect where after surgery, that fluid is just stuck and without help for it to move out to the thoracic area and out where it’s supposed to go, it needs that help. So, these are all things we want to consider. You want to measure in advance and then you want to get in there and do it and then ultimately, you want to teach, hopefully, you know, the patient has a spouse and family that's going help with dialysis because it's a lot of steps. I think even for the practicing clinician, it's a lot of practice to get down that but again, it's just so important because it can help the fluid to move out as early as possible. So, if it is a soft kind of edema that either pits, like if you press on a fruit you know, and there’s non-pitting edema and then there is more irreversible edema, where it’s at that stage of what we would call fibrosis, which is technically irreversible but you can make these cherry packs. You can use like garbanzo beans or you know, some sort of hard nut and put it in like an ace bandage wrap. You can make your own little pack and it can go under the compression garment or you can use these chucks that sort of help hush the fluid a little bit more in addition to the – just the compression that will help retain or hopefully reduce some of the fluid. It will help it from getting worse. Generally, people will say they wake up where they feel a lot of tightness and a lot of, oftentimes, that’s the lymphatics. So, there’s things that you can do to kind of soften the tissue manually with compression using a cherry pack, using you know, I can show you the diagrams but there’s a whole lot of crafty things you can do that can really go a long way. So, I think getting the body is important because it’s like, “Whoa, what are you talking about? I have to wear this weird thing on my head.” We had a head and neck cancer survivor, who is a federal agent who came in during our course and talked about it and again, a really tough guy and you know, he had to like fly on these flights to DC and he had like a gun but then he’d wear this like black face garment and you know, people are a little bit afraid and he was kind of like, you know, self-conscious about it but you know, altitude changes. You know, there is a lymphatic washout that’s supposed to occur when we go to sleep. So, you know, sleeping with a certain level of elevation, having that compression, especially in the earlier months is just really important for managing it because I think timing is so important. Just like when we think about late radiation, over time this toxicity can get worse and worse and worse, the same home is true for the lymphatic fluid. Those protein-rich cells get harder and harder over time and it can essentially create interstitial edema and fibrosis. So, the earlier the intervention, the better, you know? Go figure, right? So, these are all things that we want to get into early. And I think what a PT or OT may not always - they might not get the swallowing education that we have. So, I think not being afraid to get educated and do it yourself could also – At the same time, when you need service for that, you’re for that too if you’re able to but a lot of times, we’re sort of stuck having to do the whole thing and what’s beautiful is just the lymph drainage alone, suddenly their voice quality improves, suddenly their swallowing gets easier. Their swallow efficiency scores are higher, they do better. It’s like magic and it seems a little woo-woo when you’re learning it and doing it. And then you’re like, “It really works.” And it is very rewarding because you see something that works so well even within one session. So, yeah. [0:45:56.8] RG: Yeah, I felt that way when I did that and this was not just necessarily for head and neck cancer but I did the walk for its force on manual therapy and I remember going to that thinking, “Man, this is not what I do. I don’t get all up in people’s business.” I mean, I’m not going to open your business and brush your teeth but like to be, like touching people and doing all the things and so it was a lot. I think a lot of SLPs are not thinking that we’re going to be so physically hands-on like that and it was definitely getting out of my comfort zone but once I started, once I finished the course, I was really lucky because I went with a couple of people from my health system but I also had a couple of people that I knew in the field who were far more seasoned and then a couple of students that I knew who got to go. So, we were all there and we could make some probably inappropriate jokes about some of the things that we were doing but it kind of lightened up the mood so that we didn't feel so uncomfortable and out of our comfort zone because really, it's not - again, if you're looking at pure decision making, it's usually not about us but you do have to kind of get out of what you're used to and what the norm is, right? [0:47:09.1] FS: Absolutely. I think, I’ve been told it’s a benefit being like you know, within your first three or four years as an SLP but again, if we are still an embryo as a field, we’re in that stage, there is a lot to learn. I love that manual therapy course and you know again, people know what’s going on within their body, sometimes we can help them find if it really – sometimes as a clinician, it’s helping people break down the barriers to help themselves too, through education and through empowering the patient. So yeah, it’s a little bit like I didn’t want to do this but you know, some of the muscle tension dysphonia patients or people who have voice and again, like there’s a lot of manual therapy that comes with just doing you know, the MD Anderson protocol. You know, they are turning their head left, right, up, down, you know, they’re opening their mouth. I’m going in there, I’m you know, really trying to get in there and getting into oral cavity and massaging and stretching. And so, these are very important tools that we got to get up and get in there, get down and dirty, yeah. [0:48:12.9] RG: Yeah. Yeah, this is definitely different. I mean, and even when you think about, like you mentioned too, the benefits to voice, always amazed at the people who still don’t make the connection between voice and swallowing and the fact that your vocal cords do both those things like they’re you know, they produce voice but they protect your airway when you swallow and that was where my handy-dandy USD 40 larynx from Amazon came into place on my desk in outpatient because you know, you mentioned buy-in earlier. A lot of times, I’d have spouses or family members come in with the patient and they look at me like, “She’s so full of crap.” And I could pull that out and pull it apart and be like, “But here’s what you’re looking at anatomy-wise.” And break it down into the simplest of terms and once you do that, the patient and their caregivers tend to be like, “Okay, you know some stuff” you know? [0:49:10.4] FS: Yep, yep. [0:49:11.5] RG: But it’s important. Let them touch it, let them hold it, and then they can you know, try to feel on themselves, where they feel that tension, whether it’s you know, temporal, mandibular, if it’s you know, in more than laryngeal spaces. Once you do that, show them the anatomy, and then have them feel it, it’s a whole different ball game. [0:49:29.6] FS: Definitely, I feel like I should get that for my outpatient patients. I’ve been using this app, you know, when I took my MBS and IMP course and there’s the dysphagia app. [0:49:39.7] RG: Yeah. [0:49:40.2] FS: So, I’ll show them the normal swallow and then this is what can happen and it’s a nice visual but I think that that’s a good one that you have. I should get some more tools that can be part of my education, you know? [0:49:51.6] RG: Yeah, particularly for the geriatric age patients, they seem to really like that model of the larynx. I don’t know if it reminds them of their schooling or if it’s just the ability to be able to touch it. [0:50:04.4] FS: Sure. [0:50:05.7] RG: I don’t know. I don’t know what it is but it seems to be great and it’s not expensive, so. [0:50:10.1] FS: Tangible variance, yeah, it goes a long way, absolutely. [0:50:13.2] RG: Yeah. [0:50:14.0] FS: Yeah, but I did like the manual therapeutic course and I think you know, thinking from a holistic perspective, thinking about we’re treating the whole person, we’re treating the body, you know, are there range of motion issues? Is there rigidity going on other than actual physiological issues with the swallowing function? You know, these are all tools that are important, you know? And often, people might have their own intuition about themselves and know they just need the proper education and proper guidance but I certainly hope more clinicians are willing to be hands-on. Exercise is an important prescription to dysphagia therapy, you know? Eat and exercise, exercise and eat, mobility, brush your teeth. I enjoy taking my patients out on a walk, you know? Especially, when I was you know, on call on the weekends, patients wanted PT, I go, “All right.” You know, if they’re a moderate fall risk or if I get the okay from their PT on a Friday, I’m going to walk with them and do my therapy too. You know, not everyone would do that but I think it’s good to think outside and think about mobility as another really important factor actually, so. [0:51:26.7] RG: Well, yeah because again, you’re looking at – if you are looking at moving lymphatic tissue or maybe lymphatic fluid out of tissue, moving around, go figure. [0:51:37.7] FS: That is exactly right. It’s almost like everything’s connected, you know? [0:51:43.1] RG: Really? No, I’m kidding. Yeah, your headbone is connected to your neckbone, that kind of thing? [0:51:49.3] FS: Oh my gosh, that’s right. It is, hopefully, but yeah, I think you know, the trismus part too, you know it’s like, that was the last thing that my most recent really complex head and neck patient had was you know, it’s hard to open his mouth, you know? And it was getting worse. I think having a device and having some consistency because only seeing me once, maybe twice for a 45-minute session. So, just the consistency of having a device or having diagrams and having follow-through at home is important you know, and to hold that stretch and they should feel the stretch, it should feel like work. If it’s too easy, you’re not doing the job that you’re supposed to do and you know, just by eating, that’s going to help maintain somewhat but it really – I saw a huge difference just within a matter over a few weeks. And because this is you know, a patient that has a lot of other medical complications, I’ll just leave it at that for now. You know, I needed to kind of motivate him to want to do it. You know, I think he was really happy and couldn’t believe that he can eat again but I will tell you this, I think I was more excited than he was, you know? I do. [0:52:59.9] RG: Yeah, I think sometimes that's the case because again, you know, kind of going back to this core group piece of it, those patients often will feel like they're the only one and they're alone, where we have seen you know, a lot of different people throughout the lifespan and throughout career and you know, we've seen kind of the worst of the worst. We have seen people who don't survive and we've seen the people who are very young and maybe have issues with dysphagia for about the remainder of their lifespan. And it’s really impactful I think for clinicians because then, you know, we do get so excited and we are so motivated by those cases where we do see success and that you know, I think one thing I don’t want to misrepresent is that it’s not necessarily our success that we’re feeling. It’s the success of seeing this person get back to quality of life and doing something that’s so basic but so meaningful to them. [0:53:57.2] FS: Absolutely. Absolutely, I think it’s not until you take – you have something taken from you that you realize what a gift it is and it’s a corny thing but it’s true. These aren’t things that you necessarily appreciate until it’s gone and so to be able to restore that, you know for me, I think food is such a big part of life and comfort and culture and you know, just bonding with other people that you know, it’s just a really nice thing to be able to give someone back, to help them get back, you know? [0:54:30.8] RG: Yeah, for sure. I mean, you were just at DRS in Puerto Rico, how was the food? [0:54:35.7] FS: The food was fantastic. So, we were in San Juan and apparently, there’s like three different places that claim to be the originators of the pina colada. Of course, the hotel we stayed at claimed to be the place that was the original original but that usually happens. You know, you have two or three contenders for who is the original and the dish that I think, their most popular dish is Mofongo. Correct me if I'm wrong, it's plantains and usually there's meat in it and it's absolutely incredible. What was difficult and again, I was learning so much and getting to meet some of my real SLP heroes, which is cool and I was copiously taking notes because last year, I was so overwhelmed. I felt like I just didn't really learn as much as I wanted to, but seeing like a beautiful ocean outside, you know it's nice but it's also like, "Man, it would be nice to be outside." So, just to get to I’ve had a little bit of an outdoor time was really nice and I think it is a real community. I think I feel a lot more a part of. I think it can be really overwhelming when it’s your first time versus your second or third but yeah, the food was absolutely fantastic. Whenever I travel anywhere, I try to eat the food of the region, you know? So Mofongo was one of those foods, no question about it. And then old San Juan was fantastic as well, just a lot of culture, street art, going out and hanging out, you know, it was just really beautiful. A very artistic place, I do recommend they should have DRS there again and we should go out and explore a little bit too, amidst all the learning and connecting with other clinicians and research scientists, so. [0:56:17.1] RG: Yeah, and it definitely does give you a perspective for our patients and you know, I think for most cultures, food is definitely central, and being able to get back to that when you’ve had such a devastating course of treatment and illness that’s – because oftentimes that is the bigger part of it is the course of the treatment. That’s so much more impactful than you know, some people come in and they have very minor symptoms. If they have symptoms at all before they find out they’ve got cancer in the head and neck region and so, that part is usually the most devastating, it’s the treatment, and so to be able to give back to that central love of eating and community with food is very important. [0:57:01.9] FS: Absolutely, and just being restored to some sense of being a human again, and again, I think you know, breathing, eating, you know talking, these are the essential futures of what we do as human beings and I think sometimes when we're so busy working and you know, tired that you forget what an important role we play, you know? DRS is the Dysphagia Research Society. I think someone had a question. 9[0:57:31.3] RG: Yeah. I was just going to say that. [0:57:33.4] FS: Okay. [0:57:34.3] RG: Yes, it’s the international conference. [0:57:37.6] FS: It is an international conference. I think this year was the first time I was out of the United States. Last year, it was in San Fran, next year I believe it’s in Philadelphia. So, you guys should go, it would be great. It’s really a great learning opportunity and you realize how much you don’t know because there is such brilliant minds there that I just try to soak it all up like a sponge, so. [0:58:03.8] RG: Yeah, I just came back from our state conference, which is not nearly the magnitude of that but it is still – there is a lot would you – because I’ll say even at ASHA, you know, fan girling or fan guying, whatever you want to call it, when you, you know, you’ve read someone’s research and you follow your work and then you get to meet them and you’re like, “Ooh” and then you realize they’re just human like you but they just seem smarter. [0:58:28.4] FS: Well, I try to play it cool. I try to play – you know, I think the first time it was clear that I was fan guying, fanboying, I don’t know but just really playing it cool, and some of these people kind of end up becoming friends and mentors. You just, you know, we’re all just trying to do the best that we can. I do have a funny story, like you know I really wanted to meet Dr. Hutcheson. And you know, we like follow each other on social media and I love her work so much, and all the MD Anderson people are fantastic. She was presenting a poster and which was from one of her colleagues. She was on the paper as well and then Ed Bison and Chris Gayla came by and they were like, “Oh, are you on this paper?” I said, “I wish.” And they’re like, “Well, why don’t you present it to us.” So then, Kate was like, “Yeah, go ahead and present it.” She overheard some like, this is how I am meeting Dr. Kate Hutcheson, I’m presenting her work to her. So, I did. It tried to present it and winged it and it was awesome. It was just a great first introduction to like certainly one of my like research and clinical heroes and she was a sweetheart but it was a really funny moment, one that I definitely won’t forget. So, these are the types of things that can [inaudible 0:59:33.1] us, so. [0:59:34.6] RG: Yeah, that’s great. That’s great. Yeah, I know Ed, so he’s a good [inaudible 0:59:39.8] yeah, fellow Virginian. [0:59:42.4] FS: He is a really good [inaudible 0:59:43.2] [0:59:44.0] RG: Yeah. [0:59:44.8] FS: That’s right, he’s a fellow Virginian. Congratulations, I just want to acknowledge that you’re recently awarded as a fellow in Interstate, is that correct? [0:59:52.1] RG: Yeah, thank you. Thank you for that, I appreciate it. [0:59:55.7] FS: That’s so wonderful. No, that’s a very huge honor and well-deserved. So, I know – [1:00:00.4] RG: Yes, it’s very humbling, very humbling. [1:00:02.3] FS: It’s fantastic, what an honor, you know? [1:00:07.3] RG: Yeah. Yeah, thank you so much but you know, I think this was a really good presentation to, you know, to really cover some basics and definitely some more intermediate I think topics too but I really appreciate Fred, you joining us and being on the podcast and just talking about so many different aspects because it is hard to cover everything that we need to cover but I think this was a great overview. So, I appreciate you being willing to share your knowledge and your expertise. Thank you again, Fred. It was great to see you and we look forward to seeing you again. [1:00:43.2] FS: Yeah, Renee, this was so lovely. Thank you so much for inviting me to do this. Let’s definitely do it again. [1:00:48.9] RG: Sounds great. I’ll be in touch. [1:00:51.1] FS: Okay. [END OF INTERVIEW] [1:00:54.7] ANNOUNCER: If you have indicated that you are part of the ASHA registry and entered both your ASHA number and a complete address in your account profile prior to the course completion, we will submit earned CEUs to ASHA. Please allow one to two months from the completion date for your CEUs to be reflected on your ASHA transcript. Thank you for joining us at today's podcast. Remember to go to speechtherapypd.com to learn more about earning ASHA CEUs. We appreciate your positive reviews and support and would love for you to write a quick review and subscribe. [END] BRAINS 2200Transcript © 2024 Brainstorm[s]: Functional Neurorehab for SLPS 19