Conclusion

The approach of the MDT in this patient and family showed benefits in terms of functional and psychological adaptation. The process of structured goal-setting enabled clarification of the aims of therapy, and was useful in highlighting discrepancies between the patient's somewhat unrealistic goals, and what was more likely to be achieved. The process also gave the patient and her family an enhanced and active role in the therapy process, and an increased autonomy in the face of this

Fig. 1 Intelligibility of speech as rated on an arbitrary scale out of ten by speech and language therapist (SLT). Involuntary noises (oral clicks) decreased following botulinum toxin (BT) injections

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Pre-Therapy Behavioural 2 weeks post 4 -Heeks potf S weeks post 4 -Heeks post Therapy BT BT BT 2nd BT

Pre-Therapy Behavioural 2 weeks post 4 -Heeks potf S weeks post 4 -Heeks post Therapy BT BT BT 2nd BT

Fig. 2 Distance of tongue protrusion. The distance of involuntary tongue protrusion decreased following botulinum toxin injections, as an indication of effective injection

Fig. 3 Average time to eat one mouthful of food. Time taken to eat decreased and the amount of food wasted was reduced following botulinum toxin injections, although marked benefit was also seen with behavioural therapy
Fig. 5 Average time to eat five mouthfuls of food. The time to eat five mouthfuls was reduced following injection. A comparable effect was seen with behavioural therapy but required great effort

potentially overwhelming situation. Although not quantified, it is likely that these factors increased their ability to cope psychologically.

Review of the patient and her family is an ongoing process. In light of the expected changes in impairments with this progressive disorder, the patient and her family will be encouraged to return with suggestions and expectations of the team. The MDT will in partnership with Patient A and her family continue to negotiate if and how best we might set useful goals. As Patient A's dependence increases there

Fig. 4 Tongue protrusions during five mouthfuls. Number of tongue protrusions during eating five mouthfuls. A reduction is seen following injections. A comparable effect was seen with behavioural therapy but required great effort and supervision

may be a need to evaluate her decreasing environment. Communication aids will also need to be considered. If a short inpatient stay is indicated, the outcome will be measured by goal achievement. The guiding principle will continue to be to put Patient A at the centre of the team, and through team work to optimise her function and independence.

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