Reciprocal Influence of Mobility and Speech-Language: Advancing Physical Therapy and Speech Therapy Cotreatment and Collaboration for Adults With Neurological Conditions

Abstract

 

Mobility and speech-language impairments and limitations in adults with neurological conditions manifest not in isolated anatomical components but instead in the individual-environment system and are task-dependent. Optimization of function thus requires interprofessional care to promote participation in meaningful life areas within appropriate task and environmental contexts. Cotreatment guidelines (ie, the concurrent intervention of disciplines) were established by the physical therapy, occupational therapy, and speech-language and hearing professional organizations nearly 2 decades ago to facilitate seamless interprofessional care. Despite this, cotreatment between physical therapy and speech therapy remains limited. The purpose of this Perspective article is to encourage physical therapists and speech-language pathologists to increase interprofessional collaboration through cotreatment in the management of adults with neurological conditions. Evidence from pediatrics and basic motor control literature points toward reciprocal interactions between speech-language and mobility. We provide recommendations for clinical practice with an emphasis on the gains each discipline can provide the other. This Perspective is rooted in the International Classification of Functioning, Disability and Health model and ecological theory.

Impact

The goals of speech therapy and physical therapy are complementary and mutually supportive. Enhanced cotreatment, and collaboration more generally, between physical therapists and speech-language pathologists in the management of adults with neurological conditions can augment task-relevant conditions to improve function.

Introduction

Adults receiving rehabilitation services for neurological conditions commonly present with multiple impairments, activity limitations, and participation restrictions. The International Classification of Functioning, Disability and Health (ICF) conceptualizes function and disability as a dynamic, nonlinear interaction between health conditions and contextual (ie, personal and environmental) factors.¹ In the ICF model, 3 components of human functioning influence disability status: components of the body (structures and functions), of the whole person (activity and participation), and of the whole person embedded in a social context (environmental and personal factors).¹ Dysfunction can occur in any component to contribute to disability, and because of the nonlinear relationship among ICF components, limitations in one component may or may not lead to limitations in another. ICF-inspired rehabilitation requires looking beyond minimization of pathological conditions and associated symptoms. This biopsychosocial model encourages clinicians to consider an individual’s activities in relevant contexts.^1,2

The ICF model’s emphasis on the fit between an individual and their environment in the context of specific tasks aligns with ecological theory,² which originated in the study of perception-action. Interacting constraints among the individual, task, and environment elicit the emergence of motor patterns to fit the demands of a task goal.² In this theory, the individual-environment system is the irreducible unit of analysis.^2–4 Motor function and dysfunction cannot be reduced to relatively simple, context-independent units (eg, anatomical structures) that combine to form complex movement patterns. Rather, function and disability occur at the interface of an individual with their environment during the performance of a particular task.² Consistent with the ICF model, disability from the ecological perspective is revealed in the individual-environment system and depends on specific contextual conditions.² Implicit in this account is the recognition that function and disability transcend the boundaries of a single rehabilitation discipline and thus require interprofessional care to promote participation in meaningful life areas within appropriate task and environmental contexts.⁵

Interprofessional practice “straddles the disciplines” with solutions emerging when multiple disciplines consider a problem together, rather than in isolation.⁶ Interprofessional differs from multidisciplinary. Multidisciplinary care has become the standard for the clinical management of individuals with neurological disabilities.^7–9 Although this approach consolidates diverse skill sets and promotes continuity of care, it is also additive—disciplines remain distinct entities to solve subproblems related to larger, multifaceted issues.⁶ Interprofessional practice instead represents an interaction among disciplines.

Nearly 2 decades ago, the American Physical Therapy Association (APTA), the American Occupational Therapy Association, and the American Speech-Language-Hearing Association developed cotreatment guidelines that established clear support from each professional organization for collaborative care within a single therapy session.¹⁰ These guidelines set 3 conditions for cotreatment. First, coordination among disciplines occurs to benefit the patient, not for convenience. Second, documentation of each discipline demonstrates a sound rationale for cotreatment and indicates discipline-specific goals. Finally, single sessions are limited to 2 collaborating disciplines.

Physical therapists regularly participate in cotreatment with occupational therapists for individuals with neurological conditions such as Parkinson disease (PD)¹¹ and stroke.¹² Physical and occupational therapists share a common goal of optimizing functional mobility.¹³ Although each discipline has a unique focus, sharing this common goal acts as a scaffold for collaboration, especially when individuals demonstrate limited functional mobility in multiple areas. For example, occupational therapy can target self-care, whereas physical therapy concurrently targets the standing balance supporting self-care performance. However, efforts to study the effectiveness and occurrence of cotreatment between physical therapy and speech therapy in adult practice settings are lacking.

Although the goals of physical and speech therapy diverge more than those of physical and occupational therapy, because the latter both focus primarily on mobility, there are similarities in the overall goals of each discipline: Both physical therapy and speech therapy strive to improve quality of life and the human experience. Physical therapy seeks to do so by optimizing movement,^14,† whereas speech therapy aims to promote effective swallowing and communication.¹⁵ These goals are not just complementary but also mutually supportive because there are inherent links between mobility and speech-language function. The purpose of this Perspective article is to encourage greater interprofessional collaboration between physical therapists and speech-language pathologists, using cotreatment as a mechanism for collaboration, in the management of adults with neurological conditions. We summarize evidence in pediatrics and basic motor control research supporting this collaborative practice model. We then present possible benefits for each discipline with example intervention and assessment recommendations. Barriers, future directions, and considerations for practice are provided.

Lessons From Pediatrics

Although evidence supporting speech therapy and physical therapy cotreatment of adults is limited, there is evidence in pediatrics describing cotreatment benefits. Sylvester et al¹⁶ presented a case study of a 3-year-old child with cerebral palsy, hearing loss, visual impairment, and failure to thrive with a gastrointestinal tube for feeding. He received physical therapy and speech therapy cotreatment in preschool. The disciplines were able to collaborate and share knowledge related to positioning in a standing frame and mobility for education. Better positioning in the standing frame facilitated success in communication and social opportunities at school. The authors noted that cotreatment facilitated more seamless care, rather than speech-language and mobility gains being made in a fragmented manner.¹⁶

A recent systematic review¹⁷ evaluated the ability of mobility interventions to concurrently address language and social communication outcomes in children with autism spectrum disorder. The findings suggest that motor-based interventions, such as aquatic therapy and sensory integration therapy, can improve language skills in children with autism, with 12 of the 13 evaluated studies finding improvements in language skills. The authors recommended cotreatment between physical therapists and speech-language pathologists due to the interdependence between speech and mobility skills in children with autism. They also concluded that targeting motor skills in isolation may improve language outcomes, given the lack of evidence for a particular model of collaborative practice.¹⁷ Even in situations where specific impairments and activity limitations would traditionally only support 1 service, the authors argued for the provision of both services due to the mutual influence of the fields.¹⁷

The co-occurrence of speech sound disorders with a sensorimotor origin (ie, motor speech disorders) and sensorimotor mobility impairments is well established in children and adults with developmental disabilities, including cerebral palsy¹⁸ and autism.¹⁹ Similarly, individuals with developmental language disorder—a language disorder characterized by difficulty producing and understanding complex syntactical structures in the absence of any neurodevelopmental disorder²⁰—often also exhibit impairments and limitations in balance and coordination and lower scores on motor assessments.^21,22 Speech motor errors also co-occur with lower scores on standardized gross and fine motor skills tests.²³ Fundamental to this body of literature is the recognition that speech and language occur against a background level of motor control for postural stability and that impaired articulator movement may be reflective of more global motor control impairments and mobility limitations.^24,25 Thus, the presence of motor speech disorders in individuals with some neurodevelopmental conditions primarily involving mobility impairments and limitations and the presence of mobility impairments and limitations in children with primary speech disorders support a rehabilitation approach in which the reciprocity between speech-language and mobility can be exploited for relevant and concurrent gains in both areas of functioning.

Evidence in Motor Control

Basic motor control research suggests a reciprocal relationship between speech-language and the control of movements commonly targeted by physical therapists, like postural control and gait.^26–31 These relationships appear to emerge early in life. For example, studies of infants and young children revealed strong associations between orofacial movements and standardized measures of cognitive and language skills.³² Below, we summarize additional evidence in motor control that provides a rationale for physical therapy and speech therapy cotreatment, or for increased interprofessional collaboration more generally, in adults with neurological disabilities. The goal of cotreatment and interprofessional collaboration is to optimize the outcomes prioritized by each discipline and efficiently provide a combined benefit that may exceed the sum of benefits obtained by independently treating mobility and speech-language domains.^6,10 The selected evidence emphasizes that motor behavior is task-dependent and that speech and language are fundamental components of functional activities that can influence motor control during mobility tasks.^{26–31,33,34} Likewise, challenges and changes to mobility during task performance can alter speech and language performance.^{27,29,35–37}

Mobility and Speech

Dual-task paradigms, which often focus on performance deficits when 2 tasks are performed concurrently versus separately, reveal the reciprocal influences of speech and mobility.^27,28 Speech is a particularly useful concurrent task for demonstrating relations between speech and mobility—it is well practiced and often performed during everyday functional motor skills.²⁷ Because of the social judgment commonly accompanying impaired speech,³⁸ individuals may intentionally or unintentionally prioritize speech over mobility, thus compromising mobility. Alternatively, if a fall or injury is likely because of increased difficulty of a mobility task, speech may be modified to prioritize mobility.^27,39

Raffegeau et al²⁷ assessed dual-tasking in young adults while talking and walking in environments of varying task difficulty. Gait speed was slower when participants talked, and speech pauses were longer in more challenging gait conditions. In less challenging gait conditions, participants did not modify speech, but slowed their gait speed. The results suggest that speech was prioritized over gait in less challenging conditions, but as task challenge increased, both speech and mobility were compromised to maintain overall performance and safety.²⁷

Speech also affects postural control in healthy adults. Postural control⁴⁰ is a multidimensional construct that includes steady-state control of unperturbed stance, anticipatory control to prevent destabilization from voluntary movements or other predictable internal or external perturbations, reactive responses to unexpected balance threats, and adaptive processes enabling maintenance of postural stability in response to longer-term changes in the individual, task, or environment. Postural control is often not an end itself but rather a means to an end. It supports the performance of other behaviors and, therefore, must be modified and adaptable to facilitate performance of goal-directed tasks supraordinate to postural control (ie, suprapostural tasks), such as articulation or communication.²⁹ Interactions between postural control and speech have been documented. For instance, during a speech task with young adults, postural sway frequency increased and sway magnitude decreased.²⁸ These findings were interpreted as consistent with the ecological approach—individual factors interact with environmental and task conditions, including other motor task requirements like speech, to shape postural control.²⁸ Speech task demands alter the adopted motor strategy.

An indirect interaction between speech and postural control also has been observed in the breathing patterns of healthy older adults.^29,41 Steady-state postural control and breathing patterns are related, and breathing itself is likewise adaptive to speech.⁴² Individuals typically take larger breaths before long utterances, suggesting that speakers roughly anticipate the lengths of upcoming sentences and required air volumes.^42,43 Speakers also tend to take breaths at junctures of syntactic boundaries (ie, junctures of grammatical structures that function as categories of meaning, such as independent clauses).^44,‡

To accentuate the salient acoustic distinctions that assist listeners in parsing meaning from these linguistic units, speakers are more likely to breathe at syntactic boundaries than inside syntactic units.⁴² The relationship between speaking and breathing is challenged, however, when posture is threatened. While reading a passage, healthy older adults took fewer breaths at major syntactic boundaries and more breaths at places unrelated to syntactic boundaries when standing on an unstable surface.^29,41 Breath pauses at locations unrelated to syntactic boundaries can interfere with speech cadence and fluency. Thus, placing older adults on an unstable surface can change mobility and linguistic coordination for speech, suggesting an interaction between these domains.²⁹ The summarized findings also highlight the well-established motor phenomenon of postural-respiratory coupling—changes in breathing patterns, such as those related to speech, can produce adaptive changes in postural control.^45,46 Changes in postural control occur in deep breathing compared with quiet breathing,⁴⁷ and during breath holding after inspiration compared with after expiration.⁴⁸ Considering that respiratory muscles are also important for controlling posture,⁴⁹ these results suggest that altering speech can produce changes in respiration, and thus, in how postural control strategies accommodate altered speech. It is also important to note that static body position (eg, upright, supine) can alter breathing patterns and subsequently influence speech assessments and interventions. Thus, it has been proposed that breathing behavior should be treated in the context of a particular activity (eg, speech) and within contextually relevant body positions supportive of the activity.⁵⁰

Similarly, the link between speech and postural control found in healthy adults has been found in adults with neurological disability.²⁶ The concurrent performance of speech and a challenging postural control task impaired both speech and postural control in individuals with PD compared with 2 control groups and a single-task condition without speech.²⁶ The authors suggested that one task (speech or posture) is not prioritized over another in individuals with PD, and recommended simultaneously addressing dysarthria and postural instability.²⁶ Analysis of speech may also be informative in distinguishing among the different motor impairments and limitations of individuals with PD.⁵¹ Individuals with postural instability/gait difficulty exhibit more pronounced speech impairments (eg, abnormalities in pitch breaks, inappropriate silences) compared with more tremor-dominant impairments of individuals with PD. Such results support the notion that axial motor impairments and bradykinesia can contribute to dysarthria⁵¹ and may benefit from concurrent intervention. These benefits may be particularly important in this population given the heightened risk of injurious falls that often accompany neurological disability, particularly in older adults.^52,53

In adults with muscle tension dysphonia, a functional voice disorder, postural control was assessed before and after speech therapy.⁵⁴ A strong correlation between improvement of vocal control and steady-state postural control was found in individuals with muscle tension dysphonia. The authors use this as evidence to suggest that evaluations of speech therapy effectiveness should involve postural control assessments, because global postural control may be influenced by the muscles controlling vocal productions.⁵⁴ In another study³⁴ evaluating steady-state postural control and postural alignment in individuals with dysfunctional dysphonia, postural control changed favorably following speech therapy. The results were attributed to greater proprioceptive awareness acquired through speech therapy. Muscle dysfunction—specifically in the cervical spine and shoulder girdle—can malposition the hyoid bone and jaw, altering the position of the larynx. The forward posture typically associated with dysfunctional dysphonia can be improved through speech therapy targeting voice and breathing control. Improvement in vocal musculature position and vocal control can concurrently improve postural alignment and associated structures. Thus, the authors also recommended including postural control assessments in speech therapy evaluations, noting the reciprocal relationship between voice and postural alignment.³⁴

Beyond gait and posture, a close relationship exists between speech and upper-limb function in healthy adults. Gentilucci et al³⁵ found that the auditory amplitude of speech was influenced by grasp patterns. Participants grasped objects of different sizes, requiring different grasp patterns, while speaking different syllables. Mouth opening and acoustic power during sound production were affected by object size, and thus, grasp pattern. Specifically, lip aperture and its peak velocity were greater when grasping larger objects.³⁵ During precision grip performance, simultaneous contraction of the orbicularis oris has been observed,³⁶ which further suggests that speech and related musculature are influenced by upper-limb motor patterns.

Relationships between speech and upper-limb movements have been found in individuals with stroke as well. Individuals with a history of right hemispheric lesions demonstrated improvements in hand movement smoothness and velocity during self-vocalization of “yeah,” compared with no vocalization, external vocalization, and imagined vocalization conditions, supporting the use of speech to enhance the quality of upper-limb performance in this population.³³ The authors raised the possibility of perceptual enhancement of mobility³³ using the revised motor theory of speech perception,⁵⁵ which asserts a tight linkage between speech perception and motor speech production in that the objects of speech perception are the phonetic, articulatory gestures of the speaker. These perceptions arise from sensitivity to acoustic consequences of linguistic gestures and the embodied experiences of listeners in producing sounds of their language and learning how gestures combine/overlap in time to create meaningful communication.⁵⁵ Recent work supports this acoustic-motor coupling, finding that an individual’s voice contains perceptible acoustic signatures corresponding to their wrist movements.⁵⁶ Vocalizations can also be influenced by peripheral upper-limb movements that affect phonation acoustics.³⁷

Mobility and Language

Speech-language pathologists address areas beyond speech, typically described as language, or the cognitive-linguistic components of communication. Individuals with language disorders may have difficulty recalling information, arranging information clearly for their audience, or understanding what they read or hear.

Interactions have been noted between postural control and listening (ie, speech perception). In one study,³⁰ healthy young and middle-aged adults showed declines in postural control in more challenging listening conditions. The effect was more pronounced in middle-aged adults.³⁰ A reduced speech recognition ability was also associated with poorer postural control. These results have important implications for older and middle-aged adults³⁰ who may be at higher risk of falls, particularly when they need to communicate in challenging acoustic environments such as crowded stores. In a similar study,³¹ age-related differences in postural control and listening between younger and older adults were found when the participants were placed in a naturalistic situation with greater postural control and listening demands such as a compliant surface and high-load listening.³¹ Increased listening demands can result in poorer balance, especially in older adults who are already impacted by age-related declines in hearing and balance. Competition between listening and postural control for cognitive resources may occur with age⁵⁷ and neurological disability, supporting training in both areas for optimal functioning.

Research in interpersonal coordination provides additional examples of posture-language connections. During a cooperative verbal task that required 2 individuals to communicate to solve a puzzle, the participants’ postural dynamics (ie, trunk displacements) became coordinated.⁵⁸ Surface stability can influence this interpersonal postural coordination during verbal communication tasks: Enhanced postural coordination was observed when the participants stood on stable surfaces, but not on unstable surfaces.⁵⁹ It has been proposed that coordination during cooperative language tasks reflects the functional organization that supports the shared goals of the individuals engaged in the task and suggests a mutual influence of mobility and language.⁶⁰ Postural coordination is a fundamental aspect of language and communication, and an alteration of postural coordination can alter linguistic coordination and thus the effectiveness of communication.⁶¹

Interpersonal coordination is an important component to the participation chapter of the ICF.¹ For example, a father after stroke may want to kick a soccer ball with his daughter, or an individual after tumor resection may seek to return to work that requires coordination while lifting heavy boxes with another person. Interpersonal coordination may be difficult for physical therapists to address through intervention because it often occurs without awareness and emerges in particular task contexts.⁶² However, intentional—rather than purely spontaneous—interpersonal postural coordination is possible, particularly in skilled performers.⁶³ Language can act as a tool to facilitate coordinated movement between 2 individuals and promote the achievement of shared goals.⁶⁴ This insight may lead to the development of innovative interventions that use language, capitalizing on the expertise of speech-language pathologists, to increase either spontaneous or intentional interpersonal movement coordination. For example, in discharge planning, physical therapists can work with patients who require physical support and with their caregivers to facilitate patient-caregiver interpersonal movement coordination during a transfer task by matching postural movement patterns for weight-shifting. The speech-language pathologist can use priming techniques to help the patient and caregiver associate each step of the transfer with a salient cue that would facilitate movement coordination between the patient and caregiver.

Intervention and Assessment Recommendations

Findings from the basic motor control literature identify the reciprocity and interaction between speech-language and mobility. The summarized studies implemented mobility tasks prioritized by physical therapists—gait, posture, reaching—with the concurrent performance of speech-language tasks prioritized by speech therapists. Thus, we place emphasis on the translation of these basic motor control findings to practice via concurrent intervention. However, we do acknowledge that this model of care may not be feasible at all institutions, which we discuss further below.

The evidence summarized in this article encourages novel ways to think about cotreatment for adults with neurological disability, recognizing that some therapists may already use cotreatment in their current practice. For example, in current practice, physical therapists and speech-language pathologists may implement cotreatment for the purpose of a physical therapist facilitating seated balance or posture during swallowing interventions for an individual with intensive care unit–acquired weakness. Advancing cotreatment between physical and speech therapy may help translate the findings from basic motor control research into clinical practice through innovative interventions. Speech therapy facilitation of self-vocalization may improve upper-limb purposive motoric activities in individuals with stroke.³³ Together, the disciplines can develop interventions for improving interpersonal coordination via language and changing postural control strategies by promoting breath pauses at syntactic boundaries. These are exciting avenues for future work to investigate.

Because we take an ecological approach, wherein movement is goal-directed, task-dependent, and embedded in the environment,² perhaps the greatest benefit of cotreatment is that mobility or speech-language can be situated and treated in a task-relevant context. Increasing task relevance to enhance real-world generalizability is also consistent with several principles of neuroplasticity—salience, specificity, and transference.⁶⁵ Rather than addressing mobility and speech-language as isolated components of functioning, the ICF and ecological approach embrace the interactivity between the 2 areas of functioning—task demands impose constraints on the mobility and speech-language systems such that each must adapt for successful performance. For physical therapists, seated posture or standing balance, for instance, are valuable to the extent that they facilitate other goals.⁶⁶ Although physical therapists would not have specific goals for talking or swallowing, such outcomes are similarly important to mobility goals. In the same vein, communication and swallowing occur against a background level of postural control and mobility. Despite this, we often treat and assess mobility and speech-language as isolated components when, as shown in our brief review of the literature, they are intimately interwoven and reciprocally influence each other. If, instead, these components are practiced together, through 2 skilled disciplines, meaningful and task-relevant gains in both areas may occur.

Principles informing cotreatment differ from dual-tasking. Dual-tasking typically consists of a motor and a cognitive task, and the cognitive task incorporates listing words or serial mathematical operations, for example.^67,68 In rehabilitation, dual-tasking aims to restore diminished information-processing capacity. Cotreatment, however, is a means of incorporating additional support from a different profession during an intervention aimed at a specific goal. In short, what underlies dual-tasking is the idea of introducing additional challenges, whereas cotreatment aims to provide additional support for real-world situations, which may involve dual-tasking.

The Table presents examples of cotreatment content for impairments and activity limitations common to many neurological disabilities in adults, along with possible gains each discipline can facilitate through cotreatment. We present information related to both medical diagnosis and broader impairments and limitations that may be associated with a particular diagnosis.

Table.

Example Cotreatment Content in Neurological Settings for Physical Therapists and Speech-Language Pathologists^a

Medical Diagnosis	Impairments + Activity Limitations Relevant to Physical Therapy	Impairments + Activity Limitations Relevant to Speech Therapy	Cotreatment Content	Physical Therapy Contributions	Speech Therapy Contributions
Traumatic brain  injury	Balance and posture; coordination; gait; lifting and carrying; tone; weakness	Disinhibition; dysarthria; dysphagia; ataxia, executive function; lability; learning and applying knowledge; pragmatics; receiving verbal and nonverbal messages; memory	Individual with TBI and caregiver practice appropriate conversation/cues during transfer activity to coordinate anterior/posterior movement sway patterns	Balance training; dual-tasking; goal-directed task(s); interpersonal coordination; transfer training	Assess environmental modifications to improve intelligibility; assessment of self-monitoring skills; memory training for meaningful activity; problem-solving in task-relevant context
Parkinson disease	Bradykinesia; balance and postural control; dyskinesia; gait; maintaining position; hypokinesia; rigidity; tremor	Bradyphrenia; dysphagia; executive function; hypokinetic dysarthria; memory; speech	LSVT BIG combined with LSVT LOUD74; using speech to facilitate interpersonal coordination during activity (individual seeks to synchronize movements with therapist “model”)	Balance training; dual-tasking; interpersonal coordination; perception of ROM; perceptual enhancement of motor performance33; ROM training	Articulation practice; estimating severity of motor speech disorder in functional context; functional communication; perception of vocal loudness; self-cuing; stress testing
Stroke	Apraxia; balance and postural control; coordination; gait; grasping; maintaining position; neglect; pain; proprioception; reaching; sensation; tone; weakness	Aphasia; dysphagia; dysarthria; executive function; lability; learning and applying knowledge; memory; perseveration; pragmatics; speaking; visuospatial neglect; vocal fold dysfunction	Use of self-vocalization (eg, “yeah” or “ah”) during adapted yoga targeting breath75 and posture, such as breath work and sun salutations adapted for seated posture and hemiplegia. Individual must time breath pauses appropriately for speech and postural control; self-vocalization may also facilitate upper-limb velocity and amplitude33 for yoga activity	Assessment of task tolerance; balance training; goal-directed suprapostural task; perceptual enhancement of motor performance33; posture-respiratory coupling; reaching; speech to facilitate purposive motoric activities33; wellness training	Grasping to enhance vocalization35; problem-solving in task-relevant context; variable practice context for enhanced skill learning; visuospatial skill assessment; word finding
Amyotrophic lateral  sclerosis	Balance and postural control; fatigue; flexibility; gait; grasping; maintaining position; pain; reaching; sensation; spasticity; weakness	Breathing; fatigue; dysarthria; dysphagia; speech; using communication devices	Use of AAC devices during mobility training; concurrent mobility training (reaching, grasping) for use of AAC	Activity tolerance; balance training; dual-tasking; goal-directed suprapostural task; grasping; perceptual enhancement of motor learning; posture; reaching; ROM training	Assessment of AAC functionality when used with unfamiliar communication partners; identification of environmental modifications to support AAC use (eg, patient positioning); problem-solving in task-relevant context

^a AAC = augmentative and alternative communication; LSVT = Lee Silverman voice treatment; ROM = range of motion; TBI = traumatic brain injury.

Cotreatment Versus General Collaboration

As mentioned earlier, efforts to study the effectiveness and occurrence of cotreatment between physical therapy and speech therapy in adult practice settings are lacking. Thus, there is limited evidence to support cotreatment over more traditional collaborations that do not specifically involve cotreatment, such as grand rounds. We chose to focus specifically on cotreatment as a method of interprofessional collaboration based on the results of studies with concurrent performance of mobility and speech-language tasks. While a physical therapist can certainly engage clients in speech-language tasks, and a speech-language pathologist can engage clients in mobility tasks, both disciplines should acknowledge that there are areas that better fit the other discipline’s practice scope, providing a benefit of cotreatment. In instances where cotreatment may not be possible because of reimbursement or productivity concerns, the findings summarized in this article may provide grounds for simply increasing interprofessional collaboration. The publications by Sylvester et al¹⁶ and Odeh et al¹⁷ were discussed previously as examples of how cotreatment in pediatrics has been explored. It should be noted that those authors^16,17 also supported interprofessional practice more broadly, acknowledging, as we acknowledge, that cotreatment is just one way for interprofessional collaboration to occur. In fact, the results presented by Odeh et al¹⁷ may suggest a more unidirectional relationship between mobility and language—that is, motor-based interventions alone may improve language outcomes in children with autism. Such findings certainly support collaborative practice, but also provide grounds to further investigate interprofessional practice and identify more specific instances where cotreatment may be beneficial.

This article is intended as a starting point for discussion about increasing physical therapy and speech therapy interprofessional collaboration for adults with neurological disabilities. Cotreatment is one vehicle for this, and we provide concrete suggestions for intervention content. Empirical studies comparing the effects of cotreatment and more traditional interprofessional collaboration on patient outcomes are warranted and may elucidate whether one model of practice is better than the other. Basic motor control literature suggests an interaction between speech-language and mobility.^{27–31,33,35,41,45,48} This interaction should be leveraged to improve assessment and treatment outcomes, and both disciplines should enhance interprofessional collaboration to exploit this interaction, whether through cotreatment or more general collaboration.

Barriers

Given that only 2 disciplines are permitted to engage in cotreatment in a single session, both disciplines would also sacrifice the benefits of cotreatment with occupational therapy. Therapists must make time to coordinate schedules to ensure that both disciplines can be available at the same time. Therefore, this coordination effort may pose a challenge to meeting clinical productivity standards. Admittedly, there is an overlap among the rehabilitation disciplines.^13,69 Both speech therapy and occupational therapy, for instance, address cognitive performance and feeding, and physical therapy and occupational therapy address functional mobility. Documentation for each discipline needs to explicitly identify discipline-specific goals, while also indicating a rationale for cotreatment. Therapists are encouraged to cite literature supporting the reciprocity between speech-language and mobility for this rationale in their documentation. Relatedly, reimbursement challenges may limit conventionally defined cotreatment. In this case, increasing interprofessional collaboration in general may be more appropriate. Health care professionals may lack knowledge about other disciplines’ roles,⁷⁰ which can lead to interprofessional stereotyping and rivalry as well as poorer patient outcomes.⁷¹ Information sharing (eg, practice scope, discipline responsibilities) is particularly important to cotreatment success and collaboration. Positively, efforts are increasing in education to prepare a more collaborative practice-ready workforce.⁷²

Conclusions and Future Directions

This Perspective article provides evidence to motivate the advancement of collaborative care in the form of physical and speech therapy cotreatment in the management of adults with neurological conditions. Consistent with the ICF and ecological accounts, multiple components contribute to an individual’s function and disability, and these components interact for task performance. Mobility and speech-language are task-dependent and influenced by the environment. Practiced skills may generalize to settings outside the clinic when practice incorporates real-world task demands. As such, cotreatment of physical and speech therapy can situate mobility and speech-language in task-relevant contexts and perhaps better prepare clients for everyday, functional task demands. Future work will be required to empirically test cotreatment compared with discipline-specific therapies in adult neurological rehabilitation settings. In our work, we intend to assess therapist attitudes toward cotreatment to determine the perceived barriers and facilitators. Such research may promote a more widespread implementation of physical and speech therapy cotreatment in adult rehabilitation settings.

Notably, this is a call to action for physical therapists. There is an absence of literature in physical therapy examining the reciprocal relation between speech-language and mobility. Much of the literature summarized in this Perspective article related to pediatrics and basic motor control is from speech and communication sciences or occupational therapy journals. The desire for cotreatment and broader interprofessional collaborative efforts in this domain cannot be a one-sided concern. The American Physical Therapy Association has underscored the importance of interprofessional collaboration to address the health-related challenges of society, citing collaboration as a principle to achieve the vision of the physical therapy profession.⁷³ Cotreatment with speech-language pathologists is one simple way for physical therapists to situate their practice in the many factors contributing to health and disability, and subsequently, achieve the common goal of improving the quality of life and human experience for individuals with neurological conditions.

Author Contributions

Concept/idea/research design: S. Schwab, S. Dugan

Writing: S. Schwab, S. Dugan, M. Riley

Project management: S. Schwab

Fund procurement: S. Schwab, M. Riley

Funding

This project was funded in part by a Foundation for Physical Therapy Research Promotion of Doctoral Studies (PODS) Level I Scholarship supported by the American Physical Therapy Association Scholarship Fund and a PODS Level II Scholarship supported by the Rhomberger Fund (S.M.S.). This project was also supported in part by NIH/NIDCD grant R01DC017301. The funders played no role in the design, conduct, or writing of this Perspective article.

Conflict of Interest

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.