EPISODE 73

[INTRODUCTION]

[0:00:05] MBH: Thanks for joining us at Keys for SLPs, opening new doors for speech-language pathologists to better serve clients throughout their lifespans. A weekly audio course and podcast from speechtherapypd.com. I'm your host, Mary Beth Hines, a curious SLP who embraces lifelong learning. Keys for SLPs brings you experts in the field of speech-language pathology, as well as collaborative professionals, patients, and caregivers to discuss therapy strategies, research, challenges, triumphs, and career opportunities. Engage with a range of practitioners from young innovators to pioneers in the field as we discuss a variety of topics to help the inspired clinician thrive.

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[EPISODE]

[0:01:25] MBH: Welcome to this episode, keys to NMES and ESP for dysphagia treatment. I am your host, Mary Beth Hines. Here are the required financial and non-financial disclosures. I am the host of Keys for SLPs and receive compensation from speechtherapypd.com. I have no non-financial disclosures. Rick McAdoo is the Vice President for Ampcare. He receives compensation from speechtherapypd.com for this episode. His non-financial disclosure is that he is part of ASHA SIG 13.

Our learning objectives for today are to identify the principles of neuromuscular electrical stimulation and how they are applied to treatment of dysphagia, describe the effective swallow protocol, and explain how neuromuscular electrical stimulation, resistive swallowing exercise, and postural strategies promote a safe, effortful swallow.

Now, we welcome our guest today, Rick McAdoo, MS, CCC-SLP. Rick earned both his Bachelor of Science in 1989 and his Master of Science in Speech Language Pathology in 1990 from Texas Christian University. He has worked primarily with the adult neurogenic population with specialized emphasis in dysphagia over his entire career. Over the past 23 years, his focus has included a research and development component and was the first to show laryngeal elevation using transcutaneous electrical stimulation under video fluoroscopy.

Rick is the Vice President for Ampcare, Ampcare LLC, actually. Rick, we are so happy to have you on Keys for SLPs to talk about the principles of neuromuscular stimulation for dysphagia treatment, and Ampcare's effective swallow protocol.

[0:03:14] RM: Thanks for having me. Looking very much forward to this since you and I spoke. I really, really appreciate the platforms that people like you have put together for us as clinicians to have a chance to chat. You used to be, you'd only do that at a booth in ASHA once a month, or once a year. Now that the platforms are there, we can learn a lot from each other. I appreciate you inviting me and I look forward to the chat with you guys.

[0:03:38] MBH: Well, thank you. Well, we appreciate you accepting that invitation. Special thanks to speechtherapypd.com for making this all possible. All right. Well, will you tell us about yourself and your journey as an SLP?

[0:03:53] RM: Perfect. Yeah. ItÕs a long journey, as you said. 1989. I was pre-med. Came from a small farming community in West Texas. Coming to Fort Worth, Texas was like coming to New York City for most people. I was a little overwhelmed and wasn't prepared to do college, let's say that. Took a little time after fighting for pre-med for a full year and then my mom was a college counselor for me, kind of directed me into the voice science course. She knew I was interested in the sciences and it would fit in an elective form. That's what led me to the intro course into speech-language pathology back in the late 80s.

I had a friend who was a year ahead of me, a football player there that helped recruit me into the program. That's what got me started in speech-language pathology. I would have never known anything about it prior to taking that first voice science course. You were going to be talking a lot about dysphagia and some of the treatment options today.

I can tell you, I had my first experience in dysphagia was one lecture in the motor speech program in graduate school. I still vividly remember as the lecture was going on, we were looking at each other like, ÒIs this going to be on the test?Ó It's one of those informative lectures where we're going, ÒWait. Surely this is just, hey, it's out there.Ó It was just briefly being known. Then I get out in my graduate school, I had two 40-plus-year-old supervisors at the VA Medical Center in Dallas. I'm thinking, well, if I'm 24 and these Ð my supervisors have been out almost 20 years and they're teaching me. Everything has been learned. Still a lot outside of the degree program. It became my passion and that was the part of it.

Sharon Bena, that we're over at the VA in Dallas back in the day, who were instrumental in grabbing the tools we had then, which primarily was modified barium swallow studies, and that created my passion for swallowing and for dysphagia.

[0:05:56] MBH: Well, that's great. Was most of your clinical work done through the VA system, or did you go to Ð

[0:06:00] RM: Most of it early on was. Then my first, I guess, hospital setting outside of the VA and the training and the CF was in a hospital here in the mid-city. In the between Dallas and Fort Worth. That's where I met Russ Campbell, who's the physical therapist. I remember vividly getting credentialed to do modified swallow studies and the terms and the things that we were looking for. I remember feeling comfortable doing the study, but I was very uncomfortable when it came down to write the recommendations and what am I going to do for them?

It was very frustrating for me. I remember some patients that looked at me like, ÒYou're kidding. This is what you're going to do for my ability, or inability to swallow?Ó Is you verbally telling me to do, or I'm doing thermal stem, or tongue depressor, or cups of ice and it just played out into a way. I can get into why this came about tonight's talk, was the joint commission, everyone, I'm sure a lot of the hospital and the medical SLPs will recognize the joint commission as an accreditation for our hospitals. The big buzzword in, it's about Õ92, Õ93 was interdisciplinary care.

I was doing my own thing in my office. I knew Russ. I knew the PTs. I knew the OTs. Ronda Polansky, the other SLP within the founders of Ampcare and I had our office. We did our speech therapy and we had an office for that. But then it became where we need to do this interdisciplinary care. I remember going in there, call it three yearsÕ experience and had a Ð Russ had a patient in a standing frame. Here I come with my cup of ice and my laryngeal mirror and my tongue depressor. I see all of these things plugged in the wall and connected to this patient. It was just me. You can imagine me doing thermal stem, asking for effortful swallows, whatever, trying to teach supraglottic, trying to teach medicine, whatever I was doing. That's what alerted me that, hey, we're both doing physical medicine here. We're both doing rehab, muscular rehab. That's what got the discussion started with Russ and I. How can I take that technology to what it is that I want to do?

That was eye opening for me and that's, Russ still cusses me for that, because I brought him to the speech pathology world. Ronda and I had to teach him dysphagia and he taught us the electrophysiology. That's where it came about.

[0:08:29] MBH: It all started with a co-treat.

[0:08:30] RM: Absolutely right. I'm telling you, we could have a nice sitcom of that program. We had a 12-bed inpatient rehab. Then Ronda and I did all acute care, everything. Russ was on the inpatient rehab side and we had a great team. I mean, it's like anything else. You got great managers, you've got a great team around you and you're getting outcomes and all of us will recognize that as those are the good days, rather than handcuffing yourself, not having what you need, or not having the how it is now in a lot of places where it's just a pressure for productivity, as opposed to doing an efficient exercise and getting outcomes. I'm hoping we're trending back towards that and I take advantage of any opportunity to discuss the treatment aspect, because there's still a lot of discussion about identification, classification, grading scales on what we're seeing in modified barium swallow studies, or in the feed studies. But actual treatment aspects, what can we actually go and do? I think that's where the patients deserve to do everything that we can.

[0:09:31] MBH: They sure do. Okay, so it started with a co-treat in the early 90s. How did that relationship evolve into Ampcare?

[0:09:43] RM: I pulled up for those that are listening, the bottle cap. That was our first electrode was a little sponge and a paddle electrode trying to find the motor point. How did we get that? That's the reason there's an Ampcare is because of this. We took an approach, and I had to go back and actually reevaluate my training. I think for the most part, my anatomy and physiology and I'm quick to admit that nowadays, was a memorization. It was get through the program. I didn't feel like, at least, and that may have been my practice. I'm not telling anyone else is the same, but I wasn't applying a lot of that kinematics, the physiology of the anatomy. I wasn't applying a lot of that.

I remember Russ vividly asking me, ÒWhat is it you want to stimulate? What are you wanting to do?Ó For him, a quadricep set to contract and work on, sit to stand, or maintaining balance, all of those things made perfect sense to everyone. When I'm trying to tell him that the swallow is one to one and a half seconds and what is it you wanted to mechanically manipulate, I had to go back to my literature and go back and review anatomy. I'm not stimulating the swallow. That's not a thing. I mean, from an NMES perspective, you need to know the muscle and the nerve that you're going to cover to get that function.

One of the impairments that I think, where the speech path came from that physical therapy discipline, an electrode size and design, a focused approach on muscles that perform some part of the swallow. With 29 muscles going in one second, it's not like we can bionically create this sequence of all of those muscles firing at the right time and getting airway closure. We look at it more from the rehab perspective and the anterior digastric mylohyoid are two primary muscles that influence and facilitate the hyoid forward and upward movement. That's difficult to get from a patient sometimes. It's like educating them on the Mendelsohn. Can be challenging. But when you can depolarize that trigeminal nerve to activate and to contract that anterior digastric mylohyoid, you created this Mendelsohn-like exercise.

Getting through all of those parameters and understanding what it is that we could actually do took a lot of work. Our first white paper was written in Õ98. It went from there through several randomized trials and clinical trials and white papers and discussions, and to the point where Ampcare, I guess, was formed in 07. We felt like we had technique and a modality that was efficient.

By the way, a lot of us know there are other technologies out there using electrical stimulation. This was before there were any other technologies out there when we were working on this. It was just, I think, my perspective of what we did was Ronda and I provided the speech pathology science, AMP, if you will, and Russ provided the literature and that goes back from Õ51. Was probably one of the first studies of Dr. Osborne using NMES for hip fractures and minimizing disuse all the way to the mid-90s when we started doing this for that retrospective analysis of what parameters can be used on small muscles comfortably. Because if it hurts, then you're not doing NMES. The patient's going to tell you to turn it down. You're going to turn it up to a level that they can tolerate.

If it's just tingling, that is a tense system. That is tingling. That is aferrent, but that is not NMES. That is electrical stimulation, but it's not NMES. The NMES component would require some contraction, some depolarization of that nerve.

[0:13:27] MBH: All right. Well, let's actually, let's go back a step, because we have a variety of participants tonight. We have some people who are very experienced in the dysphagia world, and then we sometimes have students. Occasionally, weÕll have someone listen to this, who might be a patient with a swallowing problem on one of our podcast platforms in the future. Let's review the principles of neuromuscular electrical stimulation, otherwise known as NMES.

[0:13:54] RM: Sure. When you say the principles, so there's a ton, and this is my pet peeve, and I want to make sure that I focus on that discussion. There are some parameters that you need to be aware of, and it needs to be trained as clinician. Our focus as a company is to create clinicians using this modality and not technicians. I don't want you to know how to turn Ð just turn the unit on and know what buttons to push. I want you to know why, because there are some parameters that are adjustable.

There's a graph called the strength duration curve, and that sets out the parameters that you should be using from a perspective of, and this is challenging. It's challenging when I put a lot of audiovisual up, so I'm going to try to my best to create some verbiage for a podcast, so that you'll understand it. Electrical stimulation houses, I would say, hundreds, if not more, ways to use current. There's high-volt, there's pre-modulated, there's rushing stimulation, there's Iontophoresis that can drive medicine into the body, there's tins for pain, there's NMES, which is what I want to focus on now.

If you bring in, I hear clinicians sometimes say, ÒWell, I'm ESTEM certified.Ó To me, that is a graph that just lists several hundreds of ways and parameters that you've studied. We just haven't done that as a discipline. We're going to use a form of NMES. If the first parameter is pulses in a second, and it's literally, one visual that I use is like a punching bag. If you've seen boxers hit the punching bag. If you can visualize the punching bag being the muscle, and how many times do I punch it in a second.

I don't want to use punch as a detrimental, or it's a not a negative term. It's just a matter of how much facilitation you give that muscle. You can think of 30 times in a second, or 80 times in a second, or a 100 times in a second. You can see which one of those is going to be more fatiguing to the muscle, I think. You can understand that 30 is not going to be as fatiguing to that muscle as a 100 in a second. Everybody should understand that.

Now, we got to start thinking about the musculature that we're targeting, and we're talking about submental musculature, anterior digastric mylohyoid. We have to go through the platysma before we get into the anterior digastric, so there's some superficial muscles that we have to go through. Fat cells, lymph cells, lymph nodes, so that adipose tissue. There's a lot of things in our way. The depth of that current, we have to recognize that there's some parameters that can increase depth and some that may increase pain. That's what we need to make sure. The first one of those is 30 pulses in a second. That's enough for most muscles in your body to contract. That's what we chose as a company. We use a very low, if you will, manipulation of the muscle per second, and we only do it for five seconds.

That's comfortable. It's somewhat mimicking the Mendelsohn exercise. It's going to contract. We're going to work, work, work, and then it's going to give you time to rest and recuperate. That's the frequency is what I just talked about. Each one of those pulses, if you can imagine my hand touching my other hand. If it just touches and gets off like a tap, it wasn't on that hand. It wasn't on that surface very long. We're talking microseconds. Millions of seconds. You can only imagine how minute that is. But it's relative to time.

If it just taps and gets off the muscle, it's very low depth and that's the phase duration. If you touch and it actually hits and holds onto the skin surface for a period of time for longer, that's higher in the phase duration. The higher phase duration will increase depth of current. When you start thinking about the field where we're using our electrodes, do we need depth? I don't think we do. I think we've proved that in our literature that we can get the hyoid to move forward and upward by depolarizing the trigeminal nerve to get the anterior digastric mylohyoid to contract. If I can do that, that's not very deep. These muscles are band-aid thin. If you use that lower phase duration with that lower muscle manipulation, if you will, the frequency, you can get a much more comfortable contraction.

If you can create comfort and get a lot of movement, that's where you're going to take advantage of the neural muscular electrical stimulation and not just tense, or sensory. If it's comfortable, the patients can tolerate it and get that contraction to occur. That's where you can utilize this technology to create resistance. We can pull the hyoid forward. It's opening the airway. That's counterintuitive from us if we're thinking compensatory. I don't want you thinking compensatory. I want you to think about how do I make this swallow effortful? I know there's some technologies out there where we're asking for this EMG type of feedback. Oh, that was great. That looked like it was a great signal.

With the Ampcare technology, you don't have to worry of, are they getting it or not? Are they getting the contraction or not? It's visible. It's a very visible contraction, a physiological response. If you can do that using those lower parameters, I think you're on the right setting. The last one I will say is the duty cycle, or how many seconds of stimulation, how much muscle manipulation are you providing before you give them rest and recuperation?

When you're talking about swallow, that's a one second type of exercise. Let's make it effortful and let's say, hold it for five seconds. Then you give them 25, or 20, or 15 seconds of rest before they do it again. We challenge the patients with this protocol for 60, or 72, or 90 reps, up to 90 reps in that 30-minute treatment cycle. Each one of them have a bombarding afferent system through the brain stem to the cortex. The patient trying to do that swallow in return is an efferent, purposeful response that's paired with that NMES and that gives you, I think, the most effortful swallowing exercise that I can think of that you can create.

Those are three that are very important from our parameters that we really focused on and worked hard to get so that we could get it comfortable. Then we'll talk about some of the products in a bit, but the electrodes is obviously a big, big position for that.

[0:20:20] MBH: One other point of clarification. This is all done without a bolus.

[0:20:24] RM: That's correct. For MDTP, for example, bolus is the resistance. That's the effort. You can do that. You can do both, but it's a paired activity. When you're doing the Ampcare, let's call it the stimulated swallow, since we're compromising their airway, we're opening their airway during the stimulation on time and the patient has to swallow and overcome it, that's a challenge in it of itself. I don't really want to open the airway when the patient's having a hard time getting their airway closed. But there is. Within the system, there's a pause button and you also have that 25, or 20, or 15 seconds of rest time, where you could do an MDTP type swallow. You can do just some bolus swallows to keep them hydrated, keep them task-oriented, so that they're not just parched. I don't know how many saliva swallows I could do if you didn't give me an ice chip, or something bolus-related.  I think it's important and that's a really great point for the clinicians to understand, it's not that Ampcare doesn't use a bolus, it's just not part of that effortful exercise.

[0:21:28] MBH: Okay. All right. You talked a little bit earlier about how long neuromuscular electrical stimulation has been around. I didn't realize it started in the 50s.

[0:21:39] RM: Yeah. Õ51 with Dr. Osborne. If you think of any of the indications for use for NMES, one of the first ones is to prevent disuse, disuse atrophy. That was with a hip patient study with Dr. Osborne back in Õ51. That's one of the primary ones that's referenced a lot. If you're not using it, we all know we're losing it, right? If you're in a cast, for example, if anyone's been in a cast, if you can't use your arm or leg, if any of you have been in a cast, or had a family member, it's one of the most shocking things to see when they take it off. It's just that disuse atrophy muscle compared to the other.

What we want to do is if the patient can't trigger the swallow on their own, or can't do a lot, we want them to work towards that disuse. Yeah, this technology, I think that's important from the perspective of this talk, is this isn't new technology. It's new to the speech-language pathology industry. When I say new, I mean, it's been in our industry, at least from some of the technology since 20. Or no, excuse me, 01. We've had access to some of these modalities. I just don't think we knew the questions to ask.

Sometimes I think there was a high level of speech emphasis on the modality, and that's not to take anything away from the speech pathologist. But one of the things that Ronda and I first recognized was we know nothing about this technology and Russ did. He had three semesters of course work in it. Now, it's really taken a careful view of how it's been used for those 70 years, 60, I guess when we first started.

[0:23:14] MBH: Are you aware of this technology being really delved into in the current graduate curriculum?

[0:23:21] RM: It's interesting you say that. We train, there's probably Ð we're working with 30 programs in the US right now, up to. That's growing. It's difficult to change the curriculum. I think that's the first point I would say. For the graduate level programs, we train second year grad students. We have a student, great. We certify them. They don't get ASHA credit obviously, but we feel like at their last semester when they're about to graduate, that's probably the most trained they can be. We do work with the graduate programs, and to provide it as an elective. It can work in a couple of ways where the clinician just does the student, I might say. Would take the semester and do our eight hours of online, right? They can just do it at their own pace. The professors can offer that as an elective, as opposed to curriculum changing.

To my knowledge, I don't know of any of this technology being in a curriculum for the speech-language pathology world, which is fascinating to me, because it's probably one of Ð this technology in itself, it's probably one of the most researched technologies in our discipline, at least since probably 2000. There's more than 800 articles.

[0:24:31] MBH: That's a good point.

[0:24:32] RM: It's conflicting, right? We're trying to find, is it worked? Does it not work? I think that's patient specific and it's also science specific. If we follow the science that physios have used, I think it's definitely a modality we should be looking at. I'm biased. I agree. IÕm under this company, but I see the benefit.

[0:24:50] MBH: We have a question from one of our participants, asking you to review the three principles.

[0:24:56] RM: Sure, sure. Okay, so pulse rate, or frequency, that's how many pulses in a second does the pulse provide. That's what the patient is feeling. The lower the frequency, the less taxing it is on the muscle. That's thinking of the speed bag, or the punching bag. The science supports 30 hertz, 30 pulses in a second is enough for most muscles in our body to get that contraction to depolarize the nerve and to get that muscle to contract. Now, could I get a quadricep muscle to contract at 30? Maybe not. I might need more muscle manipulation and maybe more higher parameters.

But these are band-aid then. If I can get most muscles in the body, we hypothesize we could get these and we now have it under fluoro, under fees. It's on the website, where we demonstrate that physiological change, physiological appearance of muscle contraction. Frequency was one that pulses per second. The second was the phase duration. Each one of those pulses has a duration. The longer the duration, the deeper the current will penetrate. You can think about that. If you have increased depth, and here's a patient for us, head and neck cancer patient, for fibrotic patients, three and four years down the road. You might need that higher phase duration, because you're working through fibrotic tissue. That's a parameter that would be a change if you have an intact system, like the neurological patients, head, trauma, CVA, they have an intact skin and no fibrosis per se. You don't want to start off at that higher phase duration, because that's like a punch instead of a tap. That is your phase duration.

There's two phases of these pulses. There's a positive and a negative. Each one of those phases has a duration. It's in microseconds and it's very, very microscopic measurements. I think from a perspective of listening to those terms, think of it as in boxing terms, if a boxer is boxing an opponent and his glove just touches the opponent's face, doesn't even move it, barely touches it, it scores a point as a jab, but it doesn't score the point of a punch, because it just touched the skin. As opposed to a punch, where the punch actually landed and the opponent's head moved. That's a higher phase duration. That's more depth.

You have to think about our fields of interest, oral phase, submental, hyoid elevation. Those are all band-aid, small, thin muscles. We don't need the depth, so we can get away with a more comfortable contraction using the lower phase duration. Then the last one was the duty cycle, I think, we were talking about. We're on for five seconds and then we have 25, 20, or 15 seconds of rest. That's important. That means you're going to work, work, work, but you're going to also have time to rest and recuperate.

Working hard for five seconds and giving them time to rest fits more with those principles of swallowing, because it's fast-twitch. It's very fast and completed as far as an activity goes. You wouldn't want to take an exercise for a marathon runner and try to get a sprinter faster. You want to work sprinting exercises and I think that's where this fits. That's a comparison that you can review. If you know other technology, you can review those three and I think you'll get an idea of the differences. By far, two ends of the spectrum, as far as how this could be used. You can use it for afferent tingling. That's fine. That gives you an afferent signal up. We want that efferent to contract.

[0:28:30] MBH: Okay. Thank you. Hopefully, that clarified that for everyone.

[0:28:35] RM: At the end, if there's any other questions, they can feel free to contact me and Ð It's one of those things. My goal is to pique the interest that there's some substance to this technology and then even training it over eight hours, that's complicated. To do this in an hour, it's a challenge.

[0:28:51] MBH: Yes. Without any video.

[0:28:53] RM: That's right.

[0:28:54] MBH: We are in the process of planning a future webinar-based course with video on speechtherapypd.com. That may be in the future. Thank you for that question and please keep those questions coming. Okay, so let's talk about the effective swallow protocol.

[0:29:13] RM: Perfect. The protocol is relating to, so when we say ESP, it's not mind reading. We're not going to teach you how to mind read. The ESP is basically, there is an electrode. That's an E. There's an electrical stimulator. That's the ES, if you will. Then the posture device is the P. That's where the ESP came from.

By creating this effective, effortful swallowing protocol, that's where the ESP came from, the effective swallowing protocol. It's one very difficult thing to ask a patient to swallow hard and hope they're doing it. The effective swallowing protocol for us, we're creating that resistance. It's an FDA cleared system. It's not just the stimulator, it's not just the box, but it's also the electrodes. The electrodes are pie-shaped and they fit the area that we focus on. There is one placement with this protocol for submental, for the pharyngeal phase. We can target the anterior digastric mylohyoid, genial, hyoid with that placement. Those three muscles do two things. One, jaw depression, or hyoid elevation.

I don't want to say, laryngeal elevation. It helps facilitate the hyoid laryngeal process. But I think it's important for us to all understand, unless you're going to put intrinsically needle electrodes into the musculature intrinsically, you're pretty limited to how many muscles you can target. We can target that submental region with these pie-shaped electrodes and bombard it and get all the muscles we want to get from that one placement.

If you have electrodes above and below the hyoid, you're going to get into this tug of war. Our focused approach is to promote hyoid elevation, that hyoid laryngeal elevation. To do that, we facilitate that hyoid movement forward. This is my example of using the setup as an example. Somebody, a crunch, I don't know if you guys call it a crunch, a setup. What this technology does is it will help Ð if you say, I need you to do a setup and I reach out and grab your hands, Mary Beth, and you say, ÒI can't lift my head up. I can't get up.Ó But I use your hands and mine and I can help facilitate you into that setup position, right? That's the facilitation that this technology does by pulling the hyoid forward and upward.

Now, I want you to visualize a theraband that's nailed to the floor across your chest. Now as I reach out and help pull you forward, there's a theraband that's pulling you back to the floor. I'm helping you pull, work yourself through that theraband as the resistance. That's that posterior pharynx. If the hyoid goes because of stimulation, the posterior pharynx doesn't. The first thing it wants to do is bring the hyoid back. The hyoid in that swallow is having to bring this, feels like it's a sluggish posterior pharynx, but it's just the kinematics that we're creating.

That effortful swallow, that what we show now with this technology, with the electrodes and the stimulator, or before we even get to the posture devices, we can speed up how fast the airway closes. That's a parameter that we can start measuring now. Tim's medical, if you guys are in the hospital systems, the Tim's medical system, that MVP, the 5.0, I think just launched for fees and for MBS. The way I learned it, I think the swallow is better. I'm going to tell you that I'm going to change the diet. My report is going to say, they can now have X, Y, Z diet instead of the previous diet, which may have been MPO, or puree, for example.

Now I can say, you have impairments in the MBSINP profile, for example. I can demonstrate that in that MBSINP, the hyoid overall movement is diminished. The laryngeal vestibule closure time is lengthened. It's not getting closed fast enough. There are some things we can do from a kinematic, quantifying that measurement to improve it. That's what we're starting to see. It's like, the perturbation is the term. If you're lifting weights and then all of a sudden there's no weight, it just feels very light. That lets you know that it's a resistive exercise.

The last component is the posture device. If you guys can all that are listening to the podcast and you can't see, you've seen those patients that they can't lift their head. You've got the lead glove on, if you're doing a modified study and you're holding their head up and you're providing them a bolus and you've got the field of fluoroscopy, so you can see where the bolus is going, you're getting your exam. But then when you let go of the head, the head goes back down and that patient goes back to the facility and eats with their head down, right?

They don't have someone there holding them up. This posture device that we use, and you can see a picture of it there on the website, just props that patient into the proper alignment. You can get a good exam, whether it's with fees, or with modified, you can get a good exam and then how they are examined, that can determine whether you can utilize this brace with some of those low-level patients or not. If they require some positioning, you would need to not use the brace, for example, a chin tuck.

The other side of that brace is you can use that for CTAR or the chin tuck against resistance. This material of this brace can be heat molded and fit to the proper alignment. It's like a fishing pole. You push in, it's going to push back. It's not like a towel, or a ball. You push into that ball or towel, you've pushed in and you're good. There's nothing pushing you back, and this has both. You're going to push in and it's going to push you back. It's a way to use as an extrinsic resistance, like the Shaker exercise. Instead of laying your head on the ground and lifting it to gravity, now you can sit in a chair and double the amount of nerve conduction you can achieve with this posture device. That is the ESP system. It's that stimulator with the specially designed electrodes and that posture device.

[0:35:13] MBH: Okay. We have a question about the placement of the electrodes. Are they always placed above the hyoid?

[0:35:21] RM: Yes. That's an important principle using NMES. I have discussions with clinicians across the world. Some technologies will use above and below. If you use above and below, I can tell you, if you just look at your GreyÕs Anatomy imaging of anatomy, the super hyoids and the infra hyoids, if you stimulate them both with the same amount of current to the point where you get a muscle contraction, the infra hyoids have gravity on their side and they're a longer, stronger gravity assisted muscle. If you're doing them both, some data has shown that it's going to pull that hyoid down.

Now, if that's your goal, if your goal is laryngeal depression, or hyoid depression, then you would use this technology. Wherever you use electrical stimulation on the nerve and on the muscle, you're going to strengthen that muscle group. I think that's key. Some clinicians have this mindset of, ÒWell, I think I'm going to put them on the infra hyoids. I'm going to stimulate the hyoid down and I'm going to ask the patient to swallow and overcome this resistance I've created with electrical stimulation, or with NMES.Ó If you are taking it down, you're creating Ð that is not the normal movement of what our brain would signal. Never would our brain say, ÒHyoid, go down.Ó Just recognize this technology, wherever you put your electrodes, you're going to strengthen that muscle group, more so than the muscle groups that are activated outside of the stimulation.

Wrist extension would be one perfect example that's a really nice visual. If I want improved wrist extension, then I'm going to put my electrodes on my wrist extensors. I'm not going to put them on my depressors and try to lift my wrist up against the depressor stimulus. What I'm going to do is I'm going to improve my wrist extension, or not wrist extension, your wrist depression. That's a misconception. I think that's spun around a little bit in our industry. If you talk to a physical therapist about that, that's where you're going to learn. That's probably not the right way. It's not the wrong necessarily, but it's not the best way that you're going to stimulate to strengthen the muscles of that movement you're looking to acquire, or approve.

[0:37:29] MBH: Well, that makes sense. Well, we have some more questions. Okay. Thank you, everyone, for the questions. Does Medicare pay for the posture device?

[0:37:37] RM: There is a Part B, HCPCS. If your facility has a HCPCS coding system, there is an L code for the posture device. That payment is based on regions. We go over that in the training. There is a Part B Medicare code for that. On the Part A side, itÕs a DRG, itÕs part of the equipment that the patient would need. There are some CPT codes that the physical therapists and occupational therapists can bill to help you modify it for your patient to get your patient set up. It's a bracing code.

There is a couple of ways to do that, where it's either payment with modification, not from SLP, but from PT or OT, or Medicare Part B and the L code that they can use it through the HCPCS system. Hopefully, that answers that question. Yes.

[0:38:26] MBH: Okay. The SLP cannot use the bracing code. That's only a PT?

[0:38:30] RM: Bracing code. Yeah, the modifications of those bracing codes, that would be PT or OT. Again, that's your code treatment. That's what's going on from that perspective.

[0:38:40] MBH: Okay.

[0:38:41] RM: We're limited. Good time to cover that, but we've got a 92526. That's what we've got right now. That's part of that conflict that's going on within our industry with these modalities. Our goal as a company is to get a CPT code for this technology. We have to formulate that research and demonstrate, I guess, some of the differences of how this technology is being used. If you're creating some movement that's probably not what you want and you're creating some risks per se, we need to evaluate what it is our targeted goals are with using this technology.

We're very focused on improving hyoid laryngeal of elevation, for example. Then the kinematics that come from that. That's all from that effortful swallowing exercise. We are. We are going to hopefully submit our goal, even though we're FDA cleared, our goal as a company is to get CPT code. I mean, I think all of us in the discipline that have that capability, or opportunity should strive for that. I think we do. I think we have that capability.

[0:39:38] MBH: Okay. Yes. That would be good. Really, the only way that the brace can be fit would be if you were participating, that would be actually a co-treat, if you're part of that.

[0:39:47] RM: We've had patients that have had some pressure ulcers on their chest, from their chin, just being buried into it. I mean, they haven't had it up lately at all. Osteoarthritic changes, well, that's affecting me and what I'm wanting to do from a speech pathology side, not only from speech and awareness, but also swallowing mechanism. Because if I'm buried my chin into my chest, there's no room for my hyoid to go, right?

Had to heat that brace down like an accordion. You do a low resistive load over a long duration to change posture. You can't just lift that patient up and brace them. You have to do this low resistive load over a long duration. PT came in, modified it, got them up a little bit, say five to 10 degrees more. Two weeks later, we've built up that tolerance, we come in, have them eat it, stretch it open a little bit more. May say, maybe we're up at 20 degrees now. That was one of those things. There are codes for the initial fitting, and then there are codes for the reassessments and adjustments. That's payable to them.

[0:40:51] MBH: Thank you for this clarification. Then one more question from our participants, just to clarify, this is a therapeutic intervention. This is not something that you would do with a bolus and not eating a meal.

[0:41:04] RM: This is good old-fashioned rehab. If I had all of these on a visual screen, or in a classroom, I would ask this question and please, I ask, and I call it honest to week. Every week's honest to week. If the effortful swallowing is not the best therapy for swallowing, somebody say that it depends, or push back for me. That's fine. Put it in the comments. I have a very difficult time talking to patients about a particular exercise, or the things I want them to try to do. At the lowest level, at the most efficient, lowest level, the thing I know I can try to get these patients to do is to do an effortful swallow. Have them work.

That is not to say, I've seen studies where they evaluated the effortful swallow versus a normal swallow. I can tell you, the effortful swallow is not the norm. We want to resist. We want to create a very specific exercise. That's neuroplasticity 101. Task specific. Swallowing for swallowing. Love it. Make it effortful and then make it so resistance and create that resistance and then do it repetitively. That creates new pathways in these neurological patients that I think we can do.

Yeah. I think from the perspective of, is there anything compensatory about it? Absolutely not. It's an effortful exercise. It's like, do you want to have a patient really work on gait when you've got ankle weights on them? They're doing leg lifts on the table. What makes them think that they're going to be able to, if we're going to correlate swallowing to walking, would you walk better without the weights, or with the weights? When you're using the weights, that's exercise. It's time to work on that, sit to stand, or leg raises on the mat. That's so that when you are walking, you're going to be a little lighter and you're going to have a little bit of strength build up.

That's another great point on this. From the rehab perspective, the pushback sometimes is, well, they're not necessarily weak. It's not just a strengthening thing. It can be. It's strengthening as well as skill. There's a lot of skill and learning. Neuroplasticity in it of itself is a challenge for the patient. We have to challenge them, so that they can overcome it. If we just have them do some light swallowing periodically, I don't know, 10, 20, 30 times in a half hour session, I don't know that the brain is being challenged to do something different there. But when we've got this stretching going on intrinsically to have them overcome it, that makes a big difference and they can start to learn new pathways that way.

It's good old-fashioned rehab. There's nothing compensatory about it. There is a pause button. You've got a rest time between each stimulus, and some of the best case studies that we've seen incorporated MDTP and some other things like that that created some of that benefit. We're at a loss if we're looking for the one silver bullet in this industry that swallowing, we should make that as complex and as beneficial for these patients as we can. I joke around, it's like a neurologist going, ÒNope, I'm only going to use CT. I'm never going to use MRI. I'm not going to use EEG.Ó We need more and more industry, more opportunities for these patients, because not one is going to work for everybody.

[0:44:14] MBH: Well said. Okay. You called this the trifecta in swallowing therapy. Can you explain what you mean by the trifecta?

[0:44:23] RM: Trifecta. Did I say that?

[0:44:24] MBH: Well, you did back in May when we first started chatting. We put this in our Ð

[0:44:29] RM: Yeah. Who knows what I was saying then? The trifecta. Well listen, the trifecta from the neuroplasticity which we just talked about, so the repetitive. We're going to do it 60 to 72 to 90 repetitions. That's five seconds on, 25 seconds off in 30 seconds. That's one rep. You're going to do two reps per minute. If they do better, then they're going to change that rest time. We're going to lower it. Make them do more repetitions. The task specific, it's swallowing for swallowing, and then it's resistive. We're creating an intrinsic resistance to the laryngeal vestibule, stretching it open, having that patient overcome it creates task specific, repetitive, resistive exercises. That fits very much within the molds for neuroplasticity and swallowing.

I used to think, well, head and neck cancer, maybe it's not neuroplasticity, but it does become that way. If you don't have some movement, whatever the reasoning behind it, you've got to relearn some ways to compensate and overcome it. That would be for me, from a neuroplasticity standpoint. If the question was out there, what's the best patient for this technology? I think that's them. It's the neurologically, the CVA, the head trauma, those patients that neuroplasticity is going to be very much warranted to gain a new access, especially to those pathways. Hopefully, that helps on that trifecta. Who knows what I was thinking about, Mary Beth?

[0:45:54] MBH: Okay. Neuromuscular electrical stimulation, the resistance swallow exercise and the postural strategies with the restorative posture device.

[0:46:02] RM: Yes.

[0:46:02] MBH: All right.

[0:46:03] RM: Parameters, it's electrodes, it's the posture device. Those three things. It's another trifecta, but those three things are included to get you the best bang for your buck. Now, I'm going to say this, your posture device is not always used. It's not required. If a patient can tolerate it, heads up, they can use the posture device on its own at the same merit. They can take it home and do those exercises without the stimulation component as a home exercise program. In the research, you'll see we're using all three of those components, the parameters and the electrodes and the posture device.

[0:46:37] MBH: Okay. Excellent. All right. We have some time for some case studies. Being HIPAA compliant, can you tell us about some case studies where you use the neuromuscular electrical stimulation, resistance swallowing exercises, the postural strategies, and you had success, or the patient had success, rather?

[0:46:58] RM: Yeah. Let me start with one Ð wasn't a trial. Some research, it was just presented to ASHA. I think this is a good case for the stroke patient. Dr. [inaudible 0:47:08] at Western Michigan did 16 stroke patients. I think this group will understand, and if there are patients in there, this is the way we may evaluate from a scale impairment, right, from the swallow study. What he did was 16 patients, and he evaluated all of their swallows on the Rosenbeck penetration aspiration scale. He dichotomized the ones and twos, okay, being normal, and then the three to eight being on the atypical side. Some impairment were noted. Hopefully, that's going to be making sense.

There were a 175 swallows. Of those swallows, 53% fell in that one to two level. 47% were in the atypical impaired side. 20 days of Ampcare, doing this, what we just talked about that intrinsic resistance, repetitive, resistive, effortful swallowing exercise for 20 visits. I say 20 days. 20 visits. Took four to six weeks. Some patients were three days a week, some may have been five days a week.

After those 20 visits, we reevaluated them under fluoroscopy, the same 16 patients. Then that one, they had a cohort of a 195 swallows, so there were 20 additional swallows, I think, that will relate to some of these patients being able to be evaluated more. 89% of them were in the one or two, and only 11% were in the atypical three to eight.

[0:48:39] MBH: Wow, that's incredible.

[0:48:41] RM: Those are generalized stroke patients, looking at that as a parameter, penetration aspiration scale. Then the other parameter he looked at was, okay, why? Why did that occur? That's where, I think, we're taking our research data and why I like the stroke patients. The laryngeal vestibule closure time, and that is, if you were to frame those up, 30 frames per second is what I would consider industry standard, or research standard, where you can tick 30 movements of one second of real time, you can really close down on when that larynx closes, or when it starts to open back up again. We can measure that in milliseconds. These patients went from 260 milliseconds to get them closed.

On the revaluation, they're at 210. It's already 50 milliseconds faster. I mean, so you're speeding up. There's some kinematic things that start to speed up laryngeal vestibule closure. Part of that is learning to overcome that intrinsic resistance, that perturbation that we're creating. I like that, because that's about 16 different patients. One of the most difficult patients I think we had was a head and neck cancer patient who had some restructuring going on, on a trach, high degree of lymphedema. This is a time for me to jump on my soapbox on that, is the manual lymph drainage, the compression, all of that needs to be included in the rehab for these patients. It can't just be one modality by a speech pathologist. Did it help or did it not? It's got to be such a long term, multi-focus approach for these patients. It is long term.

But this patient went from wanting to kill himself. He just couldn't even close his mouth. I don't have the picture, but we have it blinded out where we could show it. Working with lymphedema, this favorite time was the compression wrap and getting wrapped and getting that fluid to withdraw and move and getting his trach out where we could start using this. This patient went three months and went from MPO to thick liquids, neck were thick with mechanical soft diet. Then he said, and we were wanting to keep seeing him and he said, ÒI'm checking out.Ó Went to the Winnebago with the wife and started hitting the country.

Now, what we emphasized with this patient and these types of patients is it's never over. I think, my training anyway was I work with you and when we plateau, man, you did great. This is where we're at. Shake your hand, ring the bell, go on. For swallowing, it just can't be that way. We can't turn these guys loose and say, where they are today is going to make sense to them in another year or two years. When they come knocking on your door and the four-month swallow is worse than they were in the acute phase.

I would stress, and I think we all know that now. We didn't know it back when I was early training, but it's a lifelong approach. They have to aggressively work stretching. There's the FAB five exercises, the pharyngeal size, I think that Dr. Hutchinson and that group down at MD Anderson, those are very, very important. We add the head back and stretch, lift the head back as far as they can, and then do that effortful swallow. You'll create a little bit additional stretch there. That was one patient.

The stroke patient, I think, that really was, I guess, impressed me and I also, again, like to talk about, some patients, when we talk about our research, it's 20 visits sometimes. I think sometimes the clinicians relate that to, ÒOh, it's just 20 visits and that's all my patient needs. If they didn't have a full correction of their dysphagia, well, it didn't work.Ó It's not like that at all. It's more, if they're making gains, you continue on.

I think, if I were to look at all of our data since Õ98, somewhere around that 35 to 40 visits, for most patients should make a fair impact. I'll say that. But one patient was 17 days and the clinician was very impressed and almost wanted to let us know that, hey, you guys said it was 20 days. I knew in two weeks that the patient had resolved now. We'd get into the arguments. Is it spontaneous recovery? Is it learning task skill? All of those things. But no one's going to not do anything for a month. Everyone's going to do the best they can for those patients.

Shaheen Hamdy's group over in the UK looked at, especially the stroke patients, you have a dominant and a non-dominant motor hemisphere for swallowing. If you swallow under functional MRI, all of us will have one area that's more dominant than the other area. It's not necessarily handedness. It's just, you could be right hand, or right-side dominant motor cortex, or left side. If you stroke in that dominant hemisphere, how do I get the non-dominant to become dominant? I have to do task specific repetitive resistive exercise.

I can really get that non-dominant to take over, because the pathway to the dominant has been affected, but I have to challenge that patient to let that happen. That relates to maybe faster than that, maybe that better, faster outcome for those patients there. I think that one, we've actually demonstrated on Ð that was actually presented at one of our state association meetings.

[0:53:53] MBH: That's very interesting.

[0:53:54] RM: Yeah. The last thing I would talk about is the lateral medullary CVA, the brainstem, the most locked-in syndromes. Those patients can make really good gains. It just takes a little bit of time. Sometimes they're trached, and you got to get them past where they can tolerate cuff deflation. They're working on passive neuro valve. They get decanulated. Some of those patients that, one in particular, day 10, they were, I guess, voice, they started voice, too and two months of therapy. It's not that 20 days, for example.

Sometimes it's two and three months. We really focus on a cranial nerve assessment to use as a weekly, at least, reference. When I started treating with my tongue depressor and my laryngeal mirror, it was treat, treat, treat. Then in four weeks, we're going to go, and we're all holding our breath. We're hoping there's going to be a change. We don't know why. If you're doing these in-depth cranial nerve assessments, you're going to start to see some of these changes happening as you're doing this therapy. They're starting to cough when they're penetrating, or aspirating their coughing and being aware of their airway, different things like that, where they're getting the effortful swallow to occur. They can overcome it.

Different things like that, we really like to focus on. I just think that it's Ð especially some of our colleagues overseas and some of the other international colleagues, sometimes I think they look at it like it's got to work in this set period of time. It's really, all of our patients are different and you can follow their progress outside of just using just the instrumentals, using them like a good cranial nerve assessment, for example.

[0:55:30] MBH: Well, that's a really good point that the research was done to be standardized in 20 visits. It doesn't mean that it's going to get that why you're training clinicians, not technicians.

[0:55:41] RM: Exactly right. 100%.

[0:55:43] MBH: Can you touch upon deflation of the cuff before starting the stimulation?

[0:55:48] RM: Yeah. The movement that we create, and that's something that I think some of the other technology when they're using it, whether it's surface EMG, or other electrical stem, you assume that there's movement, and there's a lot of times it's a subjective, tell me when and you're almost asking a patient for something as a feedback. The amount of movement you get with this technique, if the potisma is not contracting, you are not getting the intrinsic musculature to contract. It's not magic. It won't bypass the most superficial.

When you see a good amount of physiological change and the jaw opening, because these are jaw depressors, what's happening is we're creating some intrinsic movement. If the patient's cuff, they can't tolerate, it deflated and it remains inflated and you start moving that with that exercise repetitively, you're going to rub, you have the potential to rub a fistula, or some irritation to the intrinsic mucosa, where that inflated cuff moves with your therapy.

What we train is if it's a patient who can't tolerate cuff deflation, Dr. Brodsky's got some great work coming on just sensory to decanulate. The Phagenesis Group, if you're familiar with them, are doing some work for decanulating quicker. Afferent pathways can help. That's being shown to help. Well, that's the first step with AmpcareÕs approach. You have to go through afferent, or the at the brain sensory before you can get to motor. Utilize it at that afferent way, where you're not seeing the efferent response. Now, you're just working that afferent pathway. That appears to benefit these patients to decanulate, whether it's just tolerating cuff deflation, or getting rid of the trach completely.

[0:57:36] MBH: Okay. Thank you for that clarification. We have time for probably one more quick case study.

[0:57:42] RM: I think the other one is the TBI, and this was a motor vehicle accident patient. MPO was in G2 upon first eval. They did a fees first, penetrating and aspirating on all consistencies. The TBI is a little bit of a different diagnosis in that it's not a focal result, right? It's not a small stroke, or a stroke in an area could be diffused. But some of these patients, the younger ones, and I do have one more this one and one more if you want to talk a little bit about the pediatric population with it.

Yeah, so when they have that decreased pharyngeal constriction, decrease hyoid movement, that's the ideal patient. We need to recognize the impairment on the assessment. When you see a decreased pharyngeal constriction, you see decreased hyoid laryngeal elevation, the UES isn't opening, the bolus isn't passing, it's flowing back forward. Some of those areas are things we can do.

Our kinematic change will affect from base of tongue down to the UES, by just stimulating the anterior digastric mylohyoid to move the hyoid forward. Everybody thinks about this, all right. How am I stimulating the tongue? I'm not. I'm pulling the hyoid forward and upward, and that is facilitating the base of the tongue. It's that facilitation that helps in that kinematic change. The epiglottis, for example, is a cartilage. It won't retrovert by innervation, per se. I couldn't even put a stimulator on it to make a move. It's cartilage. It's cartilaginous material. It works like a valve to protect the airway if it falls down.

Bolus control and bolus size will help facilitate that. Also, the hyoid epiglottic ligament attaches to that hyoid. If I'm pulling the hyoid forward, I'm actually pulling the feed out from under the epiglottis to allow it to retrovert more. That movement that we create creates a shallowing of the vallecula and piriform. Then the anterior motion creates some inhibition to that UESPES. All of these things happen with each swallow and when we can stimulate it and repeat it. This patient in 10 sessions went from 60 reps, and we increased the reps based on accuracy. An 80% accuracy, if you're doing 48 out of 60 reps consistently, we don't want to just keep doing the same thing. That's becoming less of a challenge. Let's lower the rest and let's target 72 swallows in 30 minutes.

If they can do 58 out of 72, which is 80%, now we're going to move you to just 15 seconds of rest and you're going to do 90 reps every 30 minutes. This patient progressed nicely with accuracy, and they were using EMSD as one of those modalities to do and exercise when the stem is on. It doesn't necessarily require swallowing. This patient went from an MPO to NC level six within liquids. It was only 10 sessions.

[1:00:38] MBH: Only how many sessions?

[1:00:40] RM: 10.

[1:00:41] MBH: 10. Wow. That's incredible. That's great.

[1:00:44] RM: That's the outlier. That's the one that's nice to hear. The last one I can give you, if we have a few minutes, the pediatric population, that's one of the frequent questions we get. The adult-like swallow is what we target. I don't mean that they're swallowing as adult, but when I say adult-like swallow, I mean the patient can put something in their mouth. They're going to chew and manipulate and swallow. The birth to three months, the hyoidÕs in an elevated state. They're suck, swallow, breathe. This technology, if you think about it, is to promote hyoid laryngeal elevation. They're not in need of hyoid laryngeal elevation. Maybe only at the sensory level for that birth to three.

When it becomes that six-month, eight-month, 12-month period where they've got, some patients have strokes even. Laryngeal tracheomalacia was one recent study we did, or a case study, where the patient was 15-months-old. How do we treat that patient with a very regimented technique, where the stimulation is going to come on and I need you to swallow before it goes off? He's not going to follow that command, but we can clip the device on their belt. We put a ball cap on them. We had that coban non-adhesive wrap and made a chin strap out of that. The electrode's on.

Then the clinician, just in a 10-by-10 room on a swivel chair almost, just had a timer, knew when the stem was about to come on, would get his attention and just use a passe, use a sucker, use a lollipop, something, knowing the stem's going to come on and give them some type of an influence or status. This patient did very well. I mean, these patients are, especially from the pediatric side, they are plastic, their brains are very plastic. They can absolutely do well with task specificity and that repetition and that resistance training for sure.

[1:02:29] MBH: Well, that is great. That's a little bonus. I didn't know you were going to give a pediatric example. I'm really thinking of this as an adult intervention. Thank you for that.

[1:02:39] RM: Yes.

[1:02:39] MBH: We do have a question. Someone asked where they can access the quiz. That is on the speechtherapypd.com website under the course tab. You can answer that more specifically. If that doesn't work for that person, you can just email us. All right. If you're like me, this course Ð I would like to learn a lot more. This is a lot of information in an hour. Thank you, everyone, for hanging in there with us. It's a lot of technical information. Where could we learn more?

[1:03:08] RM: Yeah. A couple of things we can do as a company, what we do is set up introduction-like webinars, where we can literally, in a day's time, get a team together and have a chat just like we're doing now, where we can show some video. We can show some slides and give you a little bit of an introduction about the science that we're talking about. We typically do that prior to setting up the training.

We will do four different ways to train it, all live, or all online, or two methods, and we can do in hybrids, where we're doing partial online, and then either partial live, or partial Zoom. Any questions that you guys have, we have a contact button at the bottom of our website, where you can just pop it in and pop out a question. We definitely pride ourselves on that. We love keeping our hands in the clinical population. That's one of the ways we do it. We look at our trained clinicians as family, so we want to help them out.

We're all going to be patients one of these days, so we want to advance this discipline as best we can. We're going to take advantage of it. That's certainly the goal. Any questions that you have, I don't know, Mary Beth, if you have a way to furl them on to me, if they have that, feel free to do that.

[1:04:19] MBH: Yes. Can you tell us what the website is?

[1:04:21] RM: Yeah. It's ampcarellc.com, or swallowtherapy.com. If you just did Ampcare, that's an amputee company, I think up in Ohio. Ampcarellc, or swallowtherapy.com. Info@ampcarellc is an email, if you just have a question and just felt like I muddled around and didn't get the clarity. If you have more questions, that'd be fine.

[1:04:45] MBH: Thank you.

[1:04:45] RM: You need me to put that in the chat? Would that help everybody, the website?

[1:04:49] MBH: Yeah, that would be great. We'll also have that in our show notes, once we have this episode edited and on our website. Well, Rick, thank you. This has been so helpful. Thank you to all of our participants for asking such great questions. It's been really fun working with you. This is a really exciting area in our field. It's going to be exciting to see where it goes.

[1:05:13] RM: Yeah. We will keep moving it forward. Again, like I said, this platform is fantastic. I very much appreciate all that you do for our discipline. Thanks for the opportunity. I can't thank you enough for allowing me the chance to Ð I could do this all day and I love doing it and just talking about it. Just because the path that I've been on to where I'm at now, it's a great thing to look back on. I don't know if IÕd do it again, but I'm going to talk about it.

[1:05:38] MBH: Oh, well, we're so happy that you did, because you have contributed so much to our field and to the patients who use this technology. Thank you everyone and have a great night.

[1:05:48] RM: Thank you, guys, very much, Mary Beth. We'll be in touch and let me know if there's anything I can do for any of you.

[END OF EPISODE]

[1:05:53] MBH: Thanks for joining us here at Keys for SLPs, providing keys to open new doors to better serve our clients throughout the lifespan. Remember to go to speechtherapypd.com to learn more about earning ASHA CEUs for this episode and more. Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.

[END]

KFSP 73		Transcript

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