Respiratory Muscle Strength Training

Management

Inspiratory Muscle Strength Training

 Inspiratory strength training works on the muscles of inspiration the diaphragm, the intercostals. Inspiration involves contractions of the diaphragm and external intercostals, which increase intrathoracic volume and decreased volume in pressure.

 Respiration is a recoil from inspiration. Exhalation involves relaxation of the inhalation muscles, recruitment of abdominal and internal intercostals to force air out of the lungs.

Under Pressure

Pressure Threshold Devices are recommended for RMST. There are devices for Inspiratory Muscle Strength Training (IMST) and for Expiratory Muscle Strength Training (EMST).

For Dysphagia

 In dysphagia, EMST was found not only to increase greater force with the cough, enabling the patient to produce a more productive cough forcing material from the airway, but also was found to increase hyolaryngeal excursion and velar closure.

 EMST is not recommended for those on supplemental oxygen, those with COPD or people with untreated GERD.

 The EMST 150 device is a pressure threshold device with a high number of settings, AND it is the device that was used during the study. The EMST 150 is is found on the here and is relatively inexpensive at $54.95 each.  The patient used the device 5 times, 5 times a day for 5 weeks, using the “Rule of 5.”

When focusing on EMST and IMST in your therapy, you want to find a pressure threshold device to achieve maximum results similar those found in the research as referenced below.  Resistive devices may offer various levels of resistance, or a number of holes/notches which to increase the device.  Resistance can be increased or decreased depending on patient needs and function.  The Pressure Threshold Devices offer more.  Resistive devices are:  Expand-a-Lung, The Breather, PFlex and BreathBuilder.

 RMST is also indicated for voice disorders, bilateral vocal fold paralysis, professional voice users, sedentary elderly, Parkinson’s Disease (PD), Multiple Sclerosis (MS), Huntington’s, Progressive Supranuclear Palsy (PSP), stroke, healthy elderly.  RMST can also be used for ventilator weaning.

Read More 

For more information on RMST please read the following:

 EMST and Parkinson’s Disease

EMST

EMST with MS

A large number of articles regarding RMST

EMST Swallowing and PD

 Sapienza, C.M., Davenport, P.W., & Martin, A.D. (2002).  Expiratory muscle training increases pressure support high school band students.  Journal of Voice, 16, 495-501.

 Burkhead, L.M., Sapienza, C.M. & Rosenbek, J.C. (2007).  Strength-Training Exercise in Dysphagia Rehabilitation:  Principles, Procedures and Directions for Future Research.  Dysphagia 22, 251-265.

 Sapienza, C.M. (2008).  Respiratory Muscle Strength Training Applications.  Current Opinion in Otolaryngology & Head and Neck Surgery, 16, 216-220.

 Pitts, T. et al.  (2009).  Impact of Expiratory Muscle Strength Training on Voluntary Cough and Swallow Function in Parkinson’s Disease.  Chest, 135(5), 1301-1308.

 Wheeler-Hegland K.M., Rosenbek J.C. & Sapienza, C.M. (2008).  Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  JSLHR 51, 1072-1087.

You can also read more on the EMST 150 Website.

The SLP and the Dining Room

Management

 

My dining room story….

I can’t even count how many times I have started work in a new building or started a new PRN job and been told meal times so that I can go sit with patients during their meals for their therapy time.  It’s easy, right.  I go sit in the dining room and “observe” 8 patients for signs and symptoms of dysphagia that I’ve already identified and remind patient a to use a chin tuck and patient b to eat at a slower pace.

The reality

This is how I learned dysphagia therapy.  What was taught to me was to sit with them during the meal to work on trials, observe those trials and remind them to use their strategies.  The reality:  I tried to do my “job” however Mrs. Smith needed more coffee, could I be a dear and run Mrs. Brooks to the bathroom?  I could never do my “job” because I was a waitress.  With no tips.

Not only could I not do my “job”, I was not doing anything for those patients!  That is not rehabilitation.  Look at it this way, if we never stress the system and remain at status quo, how will it improve?  If I’m trying to run a 5k, I’m going to push myself to keep going a little further.  If I continue to run around the block, I will never build the strength and endurance for a longer run.  If we never challenge the swallowing system with a more difficult bolus, then how will my patient upgrade their diet.

Therapy should be…..

Therapy should not be in the dining room.  Just like I don’t want a physical therapist to show up in the middle of my meal, our patients don’t want us popping in at their meal time and “working” with them.

Remember, swallowing is a sub-maximal muscle activity.  When swallowing, the patient does not use their swallowing muscles to the fullest extent.   There may be times that you need to observe and assess a patient but seriously, that shouldn’t happen multiples times a week for multiple weeks.

How is the patient supposed to progress with the therapy if there is never any education, home exercise program or just plain working with the patient.

Let’s challenge our patients and stop just observing!

Reference

Logemann, J. A. (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-ed.

Lingual Strengthening Using Resistance

Research

Research 

Research by Dr. Lazarus and Dr. Robbins has focused heavily on lingual strengthening. Many of these research articles have proven to us that lingual strengthening using resistance such as an IOPI does increase not only tongue strength and at times, tongue mass, but also improves the overall swallow.  This same research has also shown us that using a tongue depressor can be just as effective as a more expensive device.

The tongue is often called the driving force in the swallow.

Exercise

One type of exercise we discuss in dysphagia is an isometric exercise.  Isometric is a sustained movement.  Wikipedia:

  • “Isometric exercise, a form of resistance exercise in which one’s muscles are used in opposition with other muscle groups, to increase strength, for bodybuilding, physical fitness, or strength training.”
Our field has definitely moved in the direction of exercise-based dysphagia therapy investigating resistance, intensity, repetitions.
Evidence has shown us that resistance has a huge impact on our exercise.  Look at sticking your tongue out 10 times, compared to pushing your tongue against a tongue depressor 10 times.  Weight lifters don’t build muscle or strength by simply moving their arms up and down.  They add weight and continue to increase that weight.
I’ve been reading articles by Dr. Joanne Robbins for a while.  She has compared exercises using the Iowa Oral Performance Instrument or (IOPI).   Her research consistently looks at subjects given 8 weeks of therapy or exercise.  She’s researched patients using the IOPI vs. no exercise and found that those patients given a regimen of exercise for the tongue using resistance increased tongue mass (as measured by MRI), tongue strength (as measured by the IOPI) and actually lowered Penetration/Aspiration scores, meaning decreased penetration and/or aspiration.
                                   
In another study, she found that there was no difference in using the IOPI vs. using a standard tongue depressor, pushing the tongue against the depressor elevated, anterior and lateral (both sides).

Another study (Juan et al) looked at a single patient.  A 56 year old female, 27 months s/p CVA.  This patient had undergone behavioral interventions (“swallow-specific maneuvers (eg, supraglottic swallow), swallowing sensory stimulation/enhancement (eg, thermal stimulation), postural strategies (eg, head turn), and dietary modification”), UES dilatations and G-Tube with expectoration of saliva.   She also had outpatient services including, as the authors state “traditional dysphagia therapy and an intensive, daily home practice program including swallowing-specific maneuvers (eg, Mendelsohn), range of movement exercises, and electrical stimulation (E-stim) during saliva swallowing tasks.”

Following traditional therapy:  Video Fluorscopic Swallow Study (VFSS) was completed to see the anatomy and physiology of the swallow, looking at 12 swallows and 4 bolus consistencies.  Patient was observed with liquid pooling on the vocal folds, liquid pooling in the pyriform sinus, minimal right-sided UES opening, aspiration of liquids and decreased lingual strength as measured by the IOPI.

The patient then was introduced to 8 weeks of I-PRO Therapy with a focus on the anterior and posterior tongue, followed by 5 weeks of detraining and 9 weeks of I-PRO maintenance with decreased frequency.

During the 8 weeks of I-PRO, the patient completed 10 lingual press exercises (anterior and posterior portions of the tongue) 3x/day, 3 days/week.

Detraining included 5 weeks of no lingual strengthening.   After the detraining session, patient was found to have decreased isometric pressure with reduced UES oepning.

A 9 week program of I-PRO Therapy followed the detraining, which included a less intense I-PRO program.   After the maintance program, anterior lingual pressure returned to the same level that it was after the 8 weeks of intervention.

Quality of Life was measured using the SWAL-QOL, a diet inventory was completed, lingual pressures and volumes were measured pre and post therapy.
Post I-PRO therapy, the patient went from total NPO with expectoration of saliva to a full, unrestricted oral diet, lingual pressure and volume increased with transference to increased swallowing pressure, post-swallow residue was decreased per follow-up VFSS, UES and pharyngeal pressures increased with increased UES opening (as measured by manometry) and quality of life increased.
The patient had improved swallow safety, increased to oropharyngeal intake.
Exercise needs to count for our patients.  According to exercise science literature, 10 reps, 3 times/day, 3 days/week for 8 weeks is what is recommended.
The devices

 The nice thing about these more expensive devices, such as the Iowa Oral Performance Instrument, or IOPI is that they allow visual representation of strength, but also allows you to visually set a goal for your patient.  The IOPI is a box that is attached to a tongue bulb.  The bulb is pushed between the tongue and the palate, the cheeks and the teeth or the lips and the teeth.   It gives you a visual line showing the amount of effort exerted with a number representation.  This not only allows you to track where the patient functions during that session, giving you measurable outcomes to report to insurance, but it also allows you to set a goal for your patient to try to beat.

The creator of TheraSip, those wonderful micro resistant straws I recently blogged about, has created a device called the Tongue Press.  It does not have a fancy computer with it to track or collect data regarding your patient’s strength or progress.  This is a very simple device with 2 clear plastic tubes which can be filled with water, with a red level in the top tube with bulbs on both ends.  After the device is set per instructions (included with the device) the patient puts the tongue bulb between the tongue/palate, lips/teeth or cheek/teeth and squeezes.  Strength can be measured by movement of the red level.  The nice part of this device…..it costs a mere $20.

While the computers are always nice to have and very functional, if you don’t have $1000-$2000 to spend on a device, you can always use tongue depressors for lingual strengthening or the Tongue Press.

Remember

The main thing we need to remember is to utilize evidence based practice in our therapy.  There is plenty of evidence base regarding lingual strengthening that we can incorporate into our therapy.

References:

Lazarus, C. Logemann, J.A., Huang, C.F. and Rademaker, A.W. (2003).  Effects of two types of tongue strengthening exercises in young normals.  Folia Phoniatrica et Logopaedica, 55, 199-205.

 Robbins, J.A., Gangnon, R.F., Theis, S.M., Kays, S.A., Hewitt, A.L., and Hind, J.A. (2005).  The effects of lingual exercise on swallowing in older adults.  Journal of the American Geriatric Society, 53, 1483-1489.

Robbins, J.A. (2003, March).  Oral strengthening and swallowing outcomes.  Perspectives on Swallowing and Swallowing Disorders, 12, 16-19.

Juan J, Hind J, Jones C, McCulloch T, Gangnon R, Robbins J.  Case Study:  Application of Isometric Progressive Resistance Oropharyngeal Therapy Using the Madison Oral Strengthening Therapeutic Device.   Top Stroke Rehabil. 2013 Sep-Oct;20(5):450-70. doi: 10.1310/tsr2005-450

Exercise

Management

Recent and some previous dysphagia literature emphasizes the use of exercise physiology. Researchers such Lazarus et. al, Robbins et.al, Burkhead et. al and Clark have published the need for incorporating exercise physiology into dysphagia therapy. They emphasize the need to understand the muscles involved in the swallowing mechanism, understand their function so that you can exercise those muscles in the manner in which they function for the swallow.

Many approaches are showing great strides in therapy using a food, swallowing based approach.   Using the food as resistance along with changes to the way the person is swallowing can be one of the best approaches to changing the swallowing mechanism.

When considering exercise for your patient, it’s so important to think about the principles of neuroplasticity:

  • Use it or lose it
  • Use it and improve it
  • Experience specific
  • Repetition
  • Intensity
  • Time
  • Salience
  • Age
  • Transference
  • Interference

So basically, when you work with patients with dysphagia and consider those principles of neuroplasticity, what you do matters.

Not so sure about all of these principles?  Download your Neuroplasticity Cheat Sheet here.

What else should you consider when looking at exercises for your patient?

  1.   Not all patients need to “strengthen their swallow.”   Some patients need to work on timing of the swallow, or require compensatory strategies, such as many of our patients with head and neck cancer.
  2. Evidence-based exercises.   How many times do you see patients with exercises that have absolutely no evidence to support them?  No, we shouldn’t shame these SLPs into oblivion, but shouldn’t we do our due diligence in crushing these non-EBP exercises into non-existence??
  3. Consider exercise principles.

Exercise principles:

  • Individuality
  • Trainability
  • Specificity
  • Progression
  • Overload
  • Variety
  • Rest
  • Adaptation
  • Recovery
  • Reversibility
  • Maintenance
  • Ceiling

Download your Exercise Principles Cheat Sheet here.

Exercise should incorporate:

  • Resistance
  • Speed
  • Repetition
  • Intensity
  • Load
  • Pacing
  • Fatigue
  • Target strength, timing and coordination

 The best way to work and improve the swallowing function is to swallow. Not only simply swallow, but push the swallow beyond it’s normal capacity. One way to incorporate increasing the load of the swallow is to use the effortful swallow, the masako or the Mendelsohn maneuver. The Shaker is a great load-resistant exercise to increase opening of the UES. These exercises have been researched and shown to be effective. Logemann credits the research that has been established for the Shaker exercise and the lingual strengthening exercises from Robbins to increase lingual strength, with overall strengthening of the swallow.

 

References:

Logemann, J.A. (2005). The Role of Exercise Programs for Dysphagia Patients. Dysphagia. 20: 139-140.

Clark, H.M. (2005). Therapeutic exercise in dysphagic manamgent: Philosophies, practices and challenges. Perspectives in Swallowing and Swallowing Disorders, 24-27.

 Robbins, J.A, Butler, S.G, Daniels S.K., Diez Gross, R., Langmore, S., Lazarus C.L., et al (2008). Swallowing adn dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language and Hearing Research, 51: S276-S300.

Burkhead, L.M., Sapienza, C.M., Rosenbek, J.C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures and directions for future research. Dysphagia, 22:251-265.

Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12: 400-415.

Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L. and Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 52, 1483-1489.

Lazarus, C., Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrice et Logopaedica, 55, 199-205.

Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. Archives of physical medicine and rehabilitation, 93(7), 1173-1178.

Burkhead, L. M. (2009). Applications of exercise science in dysphagia rehabilitation. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18(2), 43-48

CTAR (Chin Tuck Against Resistance)

Management, Research

Way back in 2014……

Way back in 2014, an article was published describing Chin Tuck Against Resistance.

When we look at patients with dysphagia from Pharyngoesophageal Segment (PES) dysfunction, we look at strengthening the suprahyoid muscles. These muscles assist in hyolaryngeal excursion and therefore play a part in esophageal opening.

Isokinetic vs. Isometric

CTAR vs Shaker:  Both have a component of isometric versus isokinetic. The isometric portion of the Shaker is holding the head up for 1 minute with a minute rest x 3 repetitions. The difference is, with CTAR, the patient is holding a 12 cm inflatable rubber ball and performing a chin tuck against it while seated. When performing the Shaker, the patient is lying flat on the floor and lifting their head only as if they were looking at their toes.

The isokinetic portion is 30 repetitions of up and down head movement 3 times.

This study used 40 healthy individuals (20 male, 20 female) 21-39 years of age. All participants completed the Shaker and CTAR both isometric and isokinetic as indicated above. Data was collected over one session.

What the researchers found:

CTAR:  The Chin Tuck Against Resistance was less strenuous than the traditional Shaker, with increased sEMG values during isometric and isokinetic movement. There was a significant increase for the isometric portion of the exercise. These patient had greater muscle activation using the rubber ball and a chin tuck!

Effort was required for the chin tuck, but not for the release.  The authors felt is might benefit to have the patient release compression of the ball slowly.

There was greater muscle activation for the isokinetic movement than for the isometric movement during the traditional Shaker. The Shaker also yielded considerable greater effort to lower the head to the mat.

“Clinical trials are now needed, but the CTAR exercises appear effective in exercising the suprahyoid muscles and could achieve therapeutic effects comparable to those of Shaker exercises, with the potential for greater compliance by patients.”

The Results

Overall, CTAR was an effective in exercising suprahyoid muscles in healthy participants.

This looks promising in giving us an alternative for our patients for the Shaker exercise!!

Since the initial study.

There have been several studies since the initial CTAR study in 2014.  What are the results of these newer studies you might ask?

Well……

In 2015, head and neck patients that completed CTAR had increased:

  • chin tuck strength
  • jaw opening strength
  • anterior tongue strength
  • suprahyoid muscle volume
  • maximum mouth opening

In 2016, it was found that CTAR is more specific in targeting the suprahyoid muscles than the Shaker.

In 2017, it was found that there is the same benefits from completing CTAR as there is in completing the Shaker (increased suprahyoid strength, decreased pyriform sinus residue due to increased esophageal opening).

In 2018, Park, et al found improvements in:

  • oral cavity
  • laryngeal elevation
  • epiglottic closure
  • vallecular residue
  • pyriform residue

CTAR with your patients.

I think we can all agree, CTAR is by far much easier on our patients than the Shaker.   Many struggle when lying flat on their backs and struggle to lift their head and maintain the hold.   When the exercise does not impede respiration and is easier to complete, we do see greater compliance.

References:

Yoon W.L., Khoo JKP, Liow SJR. Chin Tuck Against Resistance (CTAR):  New Method for Enhancing Suprahyoid Muscle Activity Using a Shaker-Type Exercise. Dysphagia (2014) 29: 243-248.

Sze, W. P., Yoon, W. L., Escoffier, N., & Liow, S. J. R. (2016). Evaluating the training effects of two swallowing rehabilitation therapies using surface electromyography—Chin tuck against resistance (CTAR) exercise and the Shaker exercise. Dysphagia, 31(2), 195-205.

Gao, J., & Zhang, H. J. (2017). Effects of chin tuck against resistance exercise versus Shaker exercise on dysphagia and psychological state after cerebral infarction. European journal of physical and rehabilitation medicine, 53(3), 426-432.

You, L. H., & Long, B. Y. (2017). Comparison of Shaker Exercise and Chin Tuck Against Resistance Exercise for Radiation-induced Dysphagia af-ter Nasopharyngeal Carcinoma. Chinese Journal of Rehabilitation Theory and Practice, 23(11), 1317-1320.

Park, J. S., Lee, G., & Jung, Y. J. (2019). Effects of game-based chin-tuck against resistance exercise vs head-lift exercise in patients with dysphagia after stroke: An assessor-blind, randomized controlled trial. Journal of rehabilitation medicine.

Kraaijenga, S. A. C., Van Der Molen, L., Stuiver, M. M., Teertstra, H. J., Hilgers, F. J. M., & van Den Brekel, M. W. M. (2015). Effects of strengthening exercises on swallowing musculature and function in senior healthy subjects: a prospective effectiveness and feasibility study. Dysphagia, 30(4), 392-403.

Pudding and a Straw

Management

                                                                                

Picture from: http://www.busymomboutique.com

Looking for an exercise.

Haven’t you always wanted a very simple exercise that will work and strengthen the entire swallowing mechanism using resistance?  I do as well.  I have an exercise that I use all the time with my patients.  I am usually chastised by my co-workers when having patients use this exercise.  Patients give me a strange look until they try it.

What’s it called?

This exercise has no fancy name.  I call it……..Pudding with a Straw.  It is exactly as the name implies.  The patient drinks pudding through a straw.

What does the evidence tell us?

So first, let’s look at the evidence…….  I take into account that, from reading research…..I know using a straw increases labial activation.  A thicker, heavier bolus can add resistance to the swallow and can actually increase the movements both orally and pharyngeally with the swallow because of the sensory input from the heavier bolus.   Using an effortful swallow increases sensory input to the swallowing mechanism.  Swallowing is a sub maximal event as a whole, but when the patient focuses and purposefully uses a more effortful swallow, there is an increase in the muscle contraction of the entire swallowing mechanism.  There is an increased benefit in cuing the patient to swallow the entire bolus as hard and fast as possible.  

Putting it all together

I take all of this into account and then try the method myself, to see what I feel.  When I drink pudding through a straw, not a Panera smoothie straw, not a regular drinking straw, a cocktail straw/coffee stirrer size straw, I can feel a difference.  My lips purse together with increased effort.  My tongue retracts and tightens, my jaw tightens.  I then suck enough pudding through the straw to swallow and use an effortful swallow.  At one time, I have incorporated straw use with a safe consistency bolus for most, an effortful swallow and a weighted bolus.  I have also used the entire swallowing structure.

I believe it is important and necessary that we look at the swallowing mechanism as a whole, a process, rather than 4 parts.  It’s great to break the swallowing system down into phases for descriptive purposes, but every part of the swallow is connected in some manner and every part of the swallow deserves some attention.

It’s difficult to target one portion of the swallow when actually working with swallowing.   This is where the Home Exercise Program (HEP) can be beneficial in targeting a specific muscle/muscle group when necessary.   This doesn’t mean the saying k/g words 1 million times a day.  This means evidence-based functional exercises.

Where to begin.

Keep in mind, not every patient can start at the level of a small cocktail straw/coffee stirrer or even the pudding.  I can modify the straw by either using a larger diameter straw (Panera smoothie straws seem to be the largest I’ve found at this point).  Regular drinking straws also work very well.  Not only can I change the diameter of the straw, I can change the size of the straw by cutting it in half or in thirds.  The shorter the straw, the easier the task.

Viscosity of the bolus.

The viscosity of pudding can be varied as well.  Many times I will use a thickened liquid or applesauce for patients that are not able to start with pudding.  I may work up to yogurt, without the fruit.  Then with the pudding, in my experience, I have found that sugar-free pudding seems to be the thinnest, followed by home-made, then Snack Pack pudding.  Snack Pudding, the chocolate seems to be the lesser viscous, followed by butterscotch, with vanilla having the thickest viscosity.  Room temperature vs. refrigerated also makes a difference.  Room temperature pudding is a little less tedious for the patients, while with the refrigerated, I’m also adding the temperature aspect to my sensory portion of therapy, in addition to the difficulty of the task.

What is the goal, you might ask.

I don’t write a goal for the patient sucking pudding through a straw.  We may be working on lingual strengthening, pharyngeal strengthening, tongue base retraction, labial seal.  I don’t write my notes as “the patient was able to drink a Snack Pack cup of refrigerated chocolate pudding.”  We were working on using an effortful swallow, straw sucking for increased labial seal, weighted bolus for resistance.

Now I do time my patients and keep track of the time.  I will time the patient to see how long it takes to complete the task.  As the patient gains strength with the task, the time should decrease.  You can also use e-stim or sEMG with your patient as they are completing the task.

Keep your cool.

I don’t stress if the patient needs the entire session time to complete the task.  This is what I want them to do!!  I want the patient to use an effortful swallow.  I want to apply the rules of neuroplasticity and use a specific swallowing task, applying resistance and specificity.  My patient is swallowing, using both an effortful swallow with a focus of tongue to palate contact and using a weighted bolus with the thick pudding.

A challenge

I challenge you to try this exercise.  Try the vanilla with the coffee stirrer/cocktail straws and feel what the exercise does for you!

References:

Clark, H.M. (2005).  Therapeutic exercise in dysphagia management: Philosophies, practices and challenges.  Perspectives in Swallowing and Swallowing Disorders, 24-27.

 

Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.

 

Burkhead L.M., Sapienza C.M., Rosenbek J.C.  (2007).  Strength-training exercise in dysphagia rehabilitation:  Principles, procedures and directions for future research.  Dysphagia; 22:  251-265.

 

Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial.

 

Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.

 

Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.

 

Wheeler-Hegland, K.M., Rosenbek, J.C., Sapienza, C.M.  (2008). Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  Journal of Speech, Language and Hearing Research, 51, 1072-1087.

 

Burkhead LM.  Applications of Exercise Science in Dysphagia Rehabilitation.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia) June 2009; 18: 43-48.

 

Park JW, Kim Y, Oh JC, Lee HJ.  Effortful Swallow Training combined with Electrical Stimulation in Post Stroke Dysphagia:  A Randomized Controlled Study.  Dypshagia (2012).  DOI: 10.1007/S00455-012-9403-3.

 

Bulow M, Olsson R, Ekbert O.  Videomanometric Analysis of Supraglottic Swallow, Effortful and Non Effortful Swallow and Chin Tuck in Healthy Volunteers.  Dysphagia.  (1999); 14(2):  67-72.  DOI: 10.1007/PL00009589.

FEES Following Extubation

Assessment

The 1998 Paper

Leder, Cohn and Moller investigated the incidence of aspiration following extubation in critically ill trauma patients.

The study looked at 20 patients who required oropharyngeal intubation for at least 48 hours.   All FEES were completed around 24 hours following extubation.

Remember, aspiration is when the bolus enters the airway, below the level of the true vocal cords (as defined in this study).  Silent aspiration is when there is no accompanying behavior such as a cough or throat clear with aspiration.

During this study, 9/20 (45%) of patients were found to aspirate and 4/9 (44%) were silent aspirators.   Silent aspiration was seen in 20% of this population.   8/9 of the patients that aspirated were able to resume an oral diet within 10 days of their initial FEES.

Findings during this study:

  1.  A nasogastric tube was not associated with aspiration.
  2. Traumatic intubation was noted in 5/20 patients and 4/5 of these patients aspirated.
  3. Only the Glasgow Coma Scale rating on admission exhibited a significant difference regarding aspiration status.  (Low ratings had a higher incidence of aspiration).
  4. Trauma patients have an increased incidence of aspiration.

The authors suggest that early identification of aspiration following trauma and intubation is indicated to reduce the risk of pulmonary compromise.

There are still many questions following this study, including patients intubated for shorter than 48 hours and which variables impacted aspiration (brain injury, age, traumatic intubation, sedatives, neuromuscular blockers, respiratory status).

Some newer studies indicate:

“Patients aged >55 yrs and those with vallecular stasis on FEES examination were at significantly higher risk of postextubation aspiration. All patients with pneumonia had an associated aspiration episode.”

With prolonged orotracheal intubation, patients are at risk of aspiration following extubation.  (Barquist, Brown,  Cohn,  Lundy and Jackowski)

The  incidence of aspiration determined by FEES was 56% and 25% of  patients were silent aspirators. The patients found to aspirate were intubated for a mean duration of 8 days, 7.7 days for non-aspirators.  70% of the patients who aspirated  thin liquids while 30% aspirated  puree.  63% of the patients that aspirated showed improved swallowing and tolerated an oral diet by the time of discharge.   (Ajemian, Nirmul, Anderson, Zirlen and Kwasnik)

Instrumental assessments are critical for patients, particularly after intubation 48 hours or longer.

References:

Leder, S. B., Cohn, S. M., & Moller, B. A. (1998). Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia, 13(4), 208-212.

Barquist, E., Brown, M., Cohn, S., Lundy, D., & Jackowski, J. (2001). Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial. Critical care medicine, 29(9), 1710-1713.

Ajemian, M. S., Nirmul, G. B., Anderson, M. T., Zirlen, D. M., & Kwasnik, E. M. (2001). Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management. Archives of surgery, 136(4), 434-437.

MBSS AND FEES. Why Not Both?

Assessment

MBSS VS. FEES

Whenever you read the literature, you often see MBSS vs. FEES or a similar thought comparing the two tests, attempting to find the superior, gold standard assessment.

On social media, we seem to have 2 camps.   Team MBSS and Team FEES.   You can’t be friends and in separate camps!!  (Completely joking here!!!)

Many facilities choose one test or the other.   You can either request MBSS or FEES.  They’ll have a contract for Mobile MBSS or Mobile FEES.   In the hospital, it’s either/or.

What would happen if we try to change that thought.   What if, we changed from an either/or to a both.

What If…….

What if companies had the option of both.  Maybe the ability to do both tests at one time?  Even if they are completed at different times.  Both tests give you such a varied viewpoint of the swallow while often providing the same information regarding the swallow.

The literature says……

The majority of the research tells us that we see the same pharyngeal events with FEES that we see with MBSS including decreased back of tongue control/oral containment resulting in premature posterior loss of bolus, decreased hyolaryngeal excursion, decreased epiglottic introversion, decreased laryngeal closure resulting in penetration/aspiration or vallecular residue.   We may see decreased opening of the Pharyngoesophageal Sement (PES)/Upper Esophageal Sphincter (UES)  resulting in pyriform sinus residue and maybe aspiration.  We can see residue on the posterior pharyngeal wall due to decreased pharyngeal squeeze/stripping wave.

So, in fact, with either test we can see the physiological events of the swallow that lead us into a plan of treatment.

Much of the research states that residue, aspiration, etc are all rated as more severe when using FEES.

What about the doctors

Look at physicians.   they will often order a CT scan for a stroke patient.   When this doesn’t give them all the information needed, they often then order an MRI.   The CT and MRI do give different viewpoints and provide some different information and compliment each other very well.

Anecdotal thoughts.

In my experience, not just reading the research, when a patient had a FEES (performed by me) and later had an MBSS (performed by a colleague) the findings were exactly the same leading to identical recommendations.   In fact, I did not know until after the test that the patient was going to have an MBSS and the other SLP did not know until after the test, the results from the FEES.

Changing our thinking.

So let’s work on changing our thinking to BOTH tests, not just one or the other.  Let’s educate other medical professionals that we are looking for much more than just aspiration or penetration and that we can do so much more than just change a diet.

Let’s make a change!

References:

Aviv, J. E. (2000). Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. The Laryngoscope, 110(4), 563-574.

Schatz, K., Langmore, S. E., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology, 100(8), 678-681.

Brady, S., & Donzelli, J. (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngologic Clinics of North America, 46(6), 1009-1022.

Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia, 13(1), 19-21.

Bastian, R. W. (1991). Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modified barium swallow. Otolaryngology—Head and Neck Surgery, 104(3), 339-350.

Langmore, S. E. (2003). Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior?. Current opinion in otolaryngology & head and neck surgery, 11(6), 485-489.

Mobile FEES

Resources

So many times I am asked, how to get FEES in a building.

The great part is that FEES is mobile!

What does that mean to you?  That means that if you work in a facility, there are mobile companies that will bring their FEES equipment to your facility.

Not sure where to start?  Check out these maps for FEES providers by area.

https://www.mobiledysphagiadiagnostics.com/mobile-swallow-study-locator/

https://maphub.net/FlatlandTherapy/mobile-fees-providers-04-30-2019

 

 

Myths of FEES Part 4

Resources

You know.   You can’t see anything with FEES.   It is painful and dangerous to use FEES to assess your patients.   We’ve already discussed this though in my previous 3 posts, right?

So what’s the last myth we’re going to discuss in FEES?

FEES Myth #4………   But, MBSS (Modified Barium Swallow Study) is the gold standard!

While it is true that the MBSS has been around longer and is widely used far more than FEES, FEES is a gold standard assessment.

FEES is often used to view posterior loss of bolus into the pharynx prior to the swallow, penetration, aspiration, pharyngeal residue, opening of the esophagus and in some cases retrograde backflow from the esophagus into the pharynx.   

With FEES, you are also able to view the laryngeal and pharyngeal structures, giving you a clear picture of the anatomy.   

Susan Langmore has discussed the history of FEES, including simultaneous FEES and MBSS.  Studies that compared MBSS and FEES were often simultaneously completed.

One study found that there was agreement in presence/absence of residue, however FEES rated the residue as worse (greater) with more residue in the pharynx.  Penetration Aspiration Scores (PAS) were higher or worse when rated from FEES.  (Pisegna et al 2016, Kelly et al 2007).

In her article, Dr. Langmore stated, “The results of these ‘simultaneous’ studies argue against the MBS study being the gold standard. The gold standard should represent the truth as close as we can ascertain.  FEES is more sensitive to bolus findings, and in the case of detecting the presence of a bolus, it is clearly superior.”

Both tests have clear value in assessment of dysphagia and both tests should be considered when determining best practice for your patient.   

References:  

Langmore, S. E. (2017). History of fiberoptic endoscopic evaluation of swallowing for evaluation and management of pharyngeal dysphagia: changes over the years. Dysphagia, 32(1), 27-38.

Pisegna, J. M., & Langmore, S. E. (2016). Parameters of instrumental swallowing evaluations: describing a diagnostic dilemma. Dysphagia, 31(3), 462-472.

Kelly, A. M., Drinnan, M. J., & Leslie, P. (2007). Assessing penetration and aspiration: how do videofluoroscopy and fiberoptic endoscopic evaluation of swallowing compare?. The Laryngoscope, 117(10), 1723-1727.

Langmore, S. E. (2003). Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior?. Current opinion in otolaryngology & head and neck surgery, 11(6), 485-489.