Laura Nicholls – Lead Speech and Language Therapist at The Bridge Neurological Care Centre reflects on the rehabilitative journey of her patient Angela on regaining some normality following a lengthy admission in intensive care.
Firstly there’s a couple of things you need to know about Angela before I can tell you about her journey – she isn’t usually one to let another person speak for her but I have been given full permission to share with you all the ups and downs of her rehabilitative journey. Angela has acquired the very fitting nick name of ‘The Duchess’ – this comes from her previous occupation as a community matron, her fine eye for detail, her drive for perfection and her tendency towards bossiness.
In April 2019 Angela was admitted to hospital with Myasthenia Gravis that resulted in Myasthenic crisis (respiratory failure). Myasthenia Gravis is a rare long-term neurological condition that causes muscle weakness. In Angela’s case she experienced severe difficulty swallowing, loss of voice (aphonia) and severe breathing problems.
This resulted in the insertion of a tracheostomy (A tracheostomy is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe) with 24/7 ventilation to assist with breathing. This emergency procedure can often cause weakness and structural damage that further complicates an individual’s recovery of function. Meaning that often the long lasting impact of having difficulty speaking, eating and drinking on someone’s quality of life is not fully realised until the months after initial survival has been achieved.
It is the role of a Speech and Language Therapist to provide assessment, treatment and support for individuals who have difficulties with communication, or with eating drinking and swallowing.
Angela’s swallow and voice were severely affected second to muscle weakness and poor breath support. This resulted in poor airway protection when she was eating and drinking meaning food and fluids entered the trachea and lungs rather than the oesophagus leading to the stomach. This can cause serious health concerns as can result in airway obstruction (choking), chest infections, pneumonia and death.
I worked closely with Angela to identify what was most important to her and what would make a difference to her quality of life and wellbeing. Angela identified that she would love to be able to have a gin and tonic and face time her family and friends without them having difficulty hearing her. A huge target for a lady who was Nil By Mouth with an unsafe swallow having all her nutrition and hydration needs met via a tube into her stomach (percutaneous tube) and who had a very weak voice – Angela’s friends and family would often ring her but could only have a one sided conversation as Angela’s voice was too weak to be heard over the phone.
From thorough assessment I created an intensive swallow and voice rehabilitation programme when Angela was discharged to us in August 2019 which utilised specific muscle building/strengthening exercises to target the areas of breakdown in her voice and swallow.
This programme focused on improving oral control and coordination, improving laryngeal elevation and hyoid excursion (good range of movement is required to swallow safely), improve airway protection, increase strength of cough and strengthen her vocal cords to increase strength of voice. Angela completed this programme multiple times per day – her exercises were recorded onto her iPad for her to work through daily and support her in the completion of these.
Angela’s recovery and ability to wean from ventilation was lengthy and unpredictable and times, she suffered a number of setbacks and respiratory complications during her recovery that impacted her ability to complete therapy – however she remained determined and focused on what she wanted to achieve.
By December 2019, she made significant progress in her goals, through her dedication and perseverance with her rehabilitation programme she achieved her goals. After months of being unable to eat and drink Angela’s swallow was now safe – she was able to eat and drink without difficulty or fear of choking. Angela’s voice was also a lot stronger, she went from being inaudible on the telephone to being intelligible 100% of the time and being understood in all communication environments with no incidents of communication breakdown with familiar and unfamiliar listeners.
Angela continued with her rehabilitation programme and in February 2020 she attended her local flower club meeting where she addressed all 70 attendees, delivering a 10 minute speech without difficulty, this was a major achievement given that she was struggling to make herself heard to one individual in a quiet room 6 months prior.
It was a moment of great pride when she introduced me to the audience saying, “This is Laura, my speech therapist, without whom I would not be able to speak to you all today and without whom I would not be able to enjoy this gorgeous spread you have put on for us all.” In March 2020 the tube into Angela’s stomach was removed as she no longer needed it to meet her nutrition and hydration needs – she could do this by eating and drinking herself.
The graphs above clearly show the positive outcomes she has been able to achieve through therapy, but the true outcome is written all over her face – smiling ear to ear. Through therapy Angela did not just regain the ability to speak and swallow, she gained confidence in recovering functions that she thought she had lost forever and a new appreciation for the things in life that people often take for granted. Angela has been a complete joy to work with and one of the greatest honours of my career has been to work alongside her.
Now enjoy your G&T Duchess – you deserve it.
Laura Nicholls – Lead Speech and Language Therapist
The Bridge Neurological Care Centre
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