The role of the Speech and Language Therapist in Awake Neurosurgery

This week, I attended a talk given by Professor Peter Marien from the University of Vrije, Brussels. He is a neurolinguist, and was talking about standardising a procedure for when performing awake neurosurgery involving the language areas of the brain.

Awake neurosurgery has been going on since the late 19th century, originally during the treatment of epilepsy. Since the 1970s, a neurosurgeons have been developing a procedure which involves waking the patient up during tumour resection operations in order to test which parts of their brain are involved in language. As everyone's brain is different, it is impossible to fully map which parts are involved in language (fMRI has been shown to not give a full picture). To gain a more accurate impression, the brain is stimulated using an electrode in different parts as the person talks, and each section is labelled (either with something that looks like a tiny post-it note(!) or through computer software imposing a grid on the microscope view). The areas that, when stimulated, affect language are then avoided as far as possible during the resection. As a result,  damage to linguistic areas is reduced.

Until recently these tests have been chosen, devised and carried out by the surgeon or anaesthetists present. As a result, the tests are not necessarily comprehensive - for example, just asking the patient to count to 10 and name some pictures, which does not represent all the complex language operations we carry out each day such as reading, understanding, pragmatics - and those interpreting the results are not specialists in doing so - the example Prof. Marien gave was of an anaesthetist who carried out the assessment accepting "donkey" as a label for "horse" - hello semantic substitution!

As a result, Prof. Marien is part of a team involving neuro-linguists and SLTs, focussing on championing their involvement in these operations. SLTs understand what assessments are appropriate in order to fully test receptive and expressive language: for example involving conversation, reading, understanding and expression, and identify symptoms of vocal interruption, dysarthria or aphasia more accurately. These assessments need to be carried out pre-operatively in order to discern a person's abilities (make sure they know all the words in the assessment etc) and then in theatre. 


At the moment no "gold standard" exists for  awake neurosurgery, and there is no obligation for SLTs to be involved. But with a shorter recovery period (patients are usually discharged within 5 days of the op) and reduced rehab costs, as well as better chance of language preservation it seems so important to create this, and for it to involve SLTs (or neuro-linguists).

I still have some more questions that I need to research: for example, although Prof. Marien stated each of these areas are generally distinct, presumably it is not always to preserve all of them. How do they prioritise which is saved, for example (to put it crudely) do they value receptive language over dysarthria? Also, how do you ensure that every function is tested in every brain area - presumably each section of assessment must be long enough for the electrode to be placed in every position otherwise something might be missed, but how can this be organised to avoid fatigue in the patient? 

This seems like a fascinating area to be involved in, and Prof Marien was an excellent speaker (the graphic videos helped - for a taster check out this video at 1min45secs of someone playing a violin during an operation to reduce tremors in the arm!). 

A bit of this, a bit of that

Over the past 18 months, as well as my course placements, I have been able to attend a number of additional placements in different settings. The hours I spend at these also contribute to my clinical hours, but more importantly give me even more perspective on different settings and exposure to different styles of therapists. 

One of the main things that attracted me to this career was the variety and the scope for creativity, to use your own individuality inform your intervention. It's therefore been reassuring that over the past couple of months in particular that's exactly what I've seen! But what I hadn't fully appreciated was how useful it is to pick up tips from everyone else - from extremely experienced clinicians, to your peers and other non-SLT professionals. 

One of my additional placements was at an independent practice, carrying out a nursery screen at a school. It was my first experience of independent working, and I have to admit I was wooed by the obvious flexibility and luxury of resources often lacking in NHS departments. Strict evidence based practice was the norm, with all therapy being measured quantitatively and qualitatively (while I have seen in the NHS everyone strives for this, limited time and other pressures often mean it is not as robust as would be desired). I admired the precision of the working in the practice and the minute attention to detail.

Another placement was a couple of days on a stammering management course at City Lit. This was pretty different from the paediatric language groups I was used to! Managing a group of adults requires more skills than the knowledge of stammering and management techniques. The facilitation of the group, balancing the dynamic and responding appropriately to all of the diverse personalities is a skill that must take years to fully develop. The course also introduced me to Mindfulness in SLT for the first time. Previously this was something I've only met through my own yoga classes, but it showed me the potential for its use in this setting to help with acceptance, awareness and relaxation when managing stammering. (and potentially managing PGDip deadline stress!). Definitely something I want to learn more about in the future.

Two completely different placements and two completely different views of SLT - but with new knowledge and insight that can transfer almost directly back to my ongoing, and also completely different, language unit setting.

Equality in services

First post… less about therapy itself as an outlet for some of the thoughts I’ve had about the system over the past 18 months on placement and time working in Education previous to that…

My current placement is in a pretty disadvantaged area. Most of the children have English as an Additional Language (EAL), and come from the local sprawling housing estates. Attendance and punctuality are a big concern at the school, with a current push to improve these standards through numerous incentive schemes.

While links between SES and language development and academic achievement are well documented (e.g. Campbell et al 2003), these factors go beyond the lack of financial and emotional support for development that I had assumed were the culprits.

Having sat in on annual review/progress meetings with parents, I’ve realised how intimidating they must be. We have two years of intense post-graduate education to understand how language develops: we are asking the parents to understand it all in 30 minutes. Everyone is careful to not place blame or paint a negative picture, but often parents feel guilt themselves and these meetings may reaffirm this despite best efforts otherwise. Some parents have had less than ideal experiences of the education system; many do not speak English as a first language; some cannot read; some may have language disorders themselves. Even without these factors trying to do the best for your child is difficult.

I’ve noticed the disparity between children whose parents have the resources (time, money, knowledge and willingness) to fight for the best versus those who do not have that advocate. Some of the children’s fates have been decided in tribunals as their parents fight to get the best outcome for them. Others have been neglected throughout their school life as their parents either do not realise they need help or if they do, do not realise what options are available.

More than once, in different areas, I’ve heard of children excluded from mainstream school for poor behaviour. Once they access the support and resources of a special school, these challenging behaviours disappear. Often these children have language disorders or needs that are not understood in mainstream schooling and therefore not dealt with appropriately. I would like to give the benefit of the doubt to the mainstream schools, as I have worked in many and now staff try very hard to accommodate all children, and I am sure they were struggling with limited resources to manage such specific and significant needs. Even so, exclusion it seems an extreme response to someone who clearly had severe needs. (I don’t have the head-space to debate here if this was the reaction that was needed to get the child the help so clearly required…)

Some children have parents who are now fighting to have the exclusion struck from the record, so it does not remain on file for the rest of their academic career. Others do not. Often the situation would not have gone to these lengths because these families either don’t realise they could fight it, or know how to fight it and where to get the support they need to do so.

Another family (that I know personally - not through placement), have a young son who is currently undergoing assessment for potential ASD. They are fighting for him to receive SLT while this is process going on. He’s moved from Early Years to mainstream primary, where there is much less intervention - he previously attended a language group which had a noticeable positive impact on his behaviour and general well-being: he was calmer and happier. Until he receives a diagnosis (which is not guaranteed) he is visited by the mainstream SLT in school once every half term. His parents are well-educated and financially well off, and are able to research independently how they can provide help for him themselves until something is put in place. They are persistent in contacting services to find out what is available. Many children do not have this backing.

While all the SLTs I know fight for their clients to get them the necessary support, this is an impossible battle - there are too many children needing support. The fact is that some parents can shout louder than others. But I don’t know what the solution is to this; some sort of advocacy system? An external party who understands the system who can review a child’s case to ensure they have the best support available at that time? I don’t even know what services are available, or what I would recommend to people in these situations. Every borough of London has different systems. Clearer, consistent support and information needs to be made available, and understood by all practitioners and professionals involved with children so they can recommend and refer as required.

Without it, services will remain unequal and unfair - and the children who need it most will miss out.

Introduction

Inspired by various SLT blogs (Speech and Language Thera-peers; Therapy Ideas and If Only I Had Superpowers to name a few), #slt2b and #slpeeps debates on Twitter, and my housemate Nicole's travel blog (This Is Europe 2012), I'm attempting to start my own SLT blog.

I'm currently in the final year of the Postgraduate Diploma in Speech and Language Therapy at City University London. I love the course and have no doubt it is the right career path for me. I'm still not entirely decided what path I wish to pursue when I graduate in (eek) July, as I come out of every lecture, be it aphasia, dysfluency, voice or SLI convinced that is my calling. I'm fairly sure I want to work in paediatrics, but I haven't had my adult placement yet (that is a treat for my summer block placement) so could well change my mind. I do enjoy working with parents, carers and teachers so perhaps my grown up side will come out. I can't imagine not working with children though so it's a hard call!

I'm currently on a weekly placement in a Language Unit in a fairly deprived London Borough. Over the past few months it's been a steep learning curve as I begin to take responsibility for my own caseload, but having that creative and clinical freedom is more and more enjoyable. I love trying to find new ways to teach new things, and finding out which technique works best for that particular individual over another.

I intend to blog about my experiences and thoughts about placement, university and the field as a whole; whatever takes my fancy! My aim is to clarify the thoughts that are often fleeting as I become preoccupied with essays and coursework, when in reality taking the time to think about these issues would probably help my improve my work as a developing clinician. Here goes...