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Ampcare………A new name for NMES

Ampcare NMES

I love the ASHA convention.  Why?  It gives me an opportunity to not only see all the new products and offerings in the world of Speech Pathology, but a chance to sit down with the company reps to ask my questions and to actually try the product.  NMES or E-Stim has been dominated in  the world of dysphagia by VitalStim.

Ampcare is not new in the sense that they just started the company.  Ampcare has actually been around and researching NMES (Neuromuscular Electrical Stimulation) for swallowing rehabilitation since 1993.

I actually touched on Ampcare in a previous post regarding electrodes for NMES, however at that time, they were working on FDA approval of the device, so there was little information available.  I had received an email from Ampcare discussing their product, however it was very nice to sit down with Russ and Rick and to have them explain why they are superior in the NMES market.

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NSOMES-To Use Them or Not to Use Them…..That is the Debate

This topic may seem a little off the dysphagia path, but it’s not, trust me.  I have actually thought a lot about NSOMES in my therapy as of late.  Not only does NSOME, at least in my eyes, stand for Non-Speech Oral Motor Exercises, I also use the term for Non SWALLOWING Oral Motor Exercises.  This was the March topic for the SLP Chat, which was a very interesting conversation.  I also went to a session on NSOME’s at our state convention, which actually turned into an artic course using core vocabulary which upset me immensely since I was hoping to learn a little more about NSOME’s.

 

 

First, let’s start with these exercises.  What are they?  Non-speech (swallowing) imply that these are movements that are not concurrent with producing sounds or swallows.  These are the typical stick out your tongue 10 times, move your tongue from corner to corner of your mouth.  These are actions that we use to “strengthen” the speech/swallowing mechanism by having our patients move the articulators.

 Now I’m switching to all swallowing-hey that’s what my blog is about.  It’s my blog!!  So, anyway, who hasn’t been to a facility and observed the SLP there.  What do they usually do for swallowing exercises.  Stick out your tongue, try to touch your nose with your tongue, move your tongue from corner to corner of your mouth, stick out your jaw…….all of these 10 times, 3 times a day.  So, 30 times total.  How many of these patients truly get better with only these exercises??  In my experience, very few.

 Robbins, et al wrote a very good article about neural plasticity in swallowing.  I actually reviewed that article in an earlier blog.  One principle is that plasticity is experience specific, or that to make neural changes (i.e. to the swallowing mechanism) the experience has to be specific to the actual movement.  So, to improve the swallowing mechanism, you have to practice swallowing.  To make neural changes to the swallowing system, the patient has to SWALLOW!  What a novel idea.

 Dysphagia therapy is quickly moving to a very exercise-based therapy.  No, not the typical stick out your tongue exercises.  When you exercise the swallowing system, there are very few researched techniques, however they do exist.  With all the changes in therapy and in insurance, healthcare, now is most definitely the time to move to evidence-based practice, if you haven’t already jumped on board.  I have my list of exercises that I use that are swallowing-specific and have evidence to support them.

 Tongue exercises using resistance, i.e. tongue depressor or IOPI.  Robbins et al looked at the IOPI 10x/3xday against the tongue tip, blade and dorsum with improvement with swallowing.  (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.)  Lazarus, et al looked at the IOPI vs. a tongue depressor and found that the tongue depressor exercises worked just as well as the IOPI exercises.  (Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normalsFolia Phoniatrica et Logopaedica, 55, 199-205.)  So, I have my patients use a tongue depressor and push their tongue against it using protraction, elevation, depression and lateralization, 10x each, 5x/day, 5 days/week.

 

 

 

 Mendelsohn Maneuver uses resistance with swallowing.  You can continually add resistance if you have the capability to use sEMG with your patients, which unfortunately I do not have at this time.  With the Mendelsohn, you not only have resistance, but the entire exercise involves the act of swallowing, therefore it is a relevant exercise to improve the swallow.  (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.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.) 

The Masako technique is a little bit questionable with therapy.  Yes, it does involve a swallow, however, how often do you swallow with your tongue sticking out???  This exercise should be used with caution, and should never be the only exercise you use, but may be a good exercise paired with another exercise to improve tongue base retraction.  So, possibly have the patient use the Masako and then the Mendelsohn??   (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.)

 The Shaker exercise offers not only resistance using the head as weight, but repetition of the exercise.  Logemann and Eastering both have research for the Shaker exercise available, however use caution with this exercise, particularly for cardiac patients.  I have been to a conference where I learned the Neckline Slimmer (https://www.buynecklineslimmer.com/) using the highest resistance spring can do the same as the Shaker without the strain on the patient.  However, be careful with this as there is no research out there to support this.  The Slimmer can be purchased at many stores including Walgreens and Bed Bath and Beyond.

 The effortful swallow uses an actual swallow with the added resistance by producing force with the swallow.  You have to have the patient not only “swallow hard” but an important component of the effortful swallow is to forcefully push the tongue against the palate, therefore creating pressure for the swallow.  (Bulow, M., Olsson, R. & Ekberg, O. (1999). Videomanometric analysis of suprglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia, 14, 67-72.)  (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.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.)

 There are also exercises that I use that are “swallowing-based” such as changing the consistency, texture, weight of the bolus, one of my favorite exercises (you’d know this if you read my previous blog posts) is having the patient suck pudding through a straw and then change to a smaller straw as the patient progress.  This not only has the person swallow but strengthens the oral phase of the swallow through sucking, which is a natural motion of swallowing (we all use a straw at some point).  Mastication exercises are good, if the patient is not appropriate for an actual bolus, I use a mesh baby feeder or cheese cloth.  Any exercise you can have the patient complete that adds resistance or complication to their natural swallow is what we need.  Remember, evidence-based can also be what YOU trial, track and possibly research.  

 Now, there are times that I do use NSOME’s, I know, right, gasp.  I find that STRETCHING the articulators/swallowing mechanism is quite good for patients that have been through radiation therapy, for example.  If they are unable to move the articulators to the maximum benefit, yes, I will combine oral stretches/massage/myofascial release to the mix (above exercises) for maximum benefit.

 

 Will tongue exercises, jaw exercises, etc work outside of the context of swallowing/speech, I really don’t think they will.  You have to train the muscles to do what they’re supposed to do for function.  To do that, you HAVE to combine exercise/therapy with the intended movement.  You cannot rehabilitate speech without using speech and you cannot rehabilitate swallowing without having your patient swallow, even if it is only their own secretions.  Make certain that what you are doing is working for your patient, if the tongue exercises don’t seem to be changing anything, by the data you track, change what you are doing!  We are therapists adn are trained to use a variety of techniques.  If you are uncertain about where to go next, ask.  Don’t be afraid to ask questions.  

 When having your patients exercise, whether it be the speech or swallowing system, look to your physical therapist for ideas.  They exercise their patients, however they relate the exercise to the actual act (i.e. walking) and combine the exercises with the act of walking.  They don’t have their patients do leg exercises and send them home expecting them to walk with more efficiency.  They also exercise their patients with walking and make it more difficult (without the walker).  

 Remember when using Swallowing Oral Motor Exercises, use plenty of repetition, add resistance and make it worth your and your patient’s time!

 

 

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Electrodes…..Are they really all the same??

Electrodes for NMES

NMES

One of the biggest controversies in dysphagia therapy has to be NMES or Neuromuscular Electrical Stimulation, to use it or to not use it.  It has been extensively researched, although results of the research vary.

Whether you believe in NMES for dysphagia or use NMES, you need to understand the facts between the electrodes.  It’s not just about cost, the construct, impedance and versatility are also important.

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Pre-Made Pureeds…..Not All the Same

I’ve had the opportunity recently to sample some different pureed foods.  Ok, so I wasn’t exactly jumping for joy with the thought of trying different pureeds, or pureed food at all, but I figured it couldn’t hurt.  Besides, if I’m going to feed patients this food or recommend it for my patients, I should know the best pureed foods to recommend.

This is what I’ve always seen with a pureed diet:

A lot of food that I can make an educated guess as to what it is, I’m just not really sure what it is.

With food molds becoming more readily available, your pureed food can actually look like this:

Blossom Foods has pureed foods available, however I’ve never seen or tried their food.

Thick-It has had foods available for some time.  I’ve looked at these foods and could never stomach trying them.  I think most of us know Thick-It though for the thickeners they produce.

The Thick-It website states their purees are:

Ideal for Caregivers & Healthcare Providers with Dysphagia Patients

Thick-It® Purees were designed to be convenient for people with dysphagia and their caregivers who may not have the time, resources or patience to blend their own pureed foods. At a ready-to-eat consistency, Thick-It® Purees can be swallowed safely and easily, and may reduce the risk of aspiration pneumonia, a potentially life-threatening complication of dysphagia. Patients can receive the proper nutritional benefits while enjoying a wide variety of food options. A complete list of nutrition information is available, including our list of gluten-free products and allergen information.

 

Thick-It® Purees are Ideal for Any Time of Day


Our purees come in 15 varieties and are perfect for breakfast, lunch, dinner and snacks.

      • Entrees: Beef in Barbecue Sauce, Beef Lasagna, Beef Stew, Chicken a la King, Salisbury Steak, and Seasoned Chicken Patty
      • Breakfast: Maple Cinnamon French Toast, Omelet with Sausage and Cheddar Cheese 
      • Sides: Carrot & Pea, Seasoned Green Bean, Sweet Corn, Seasoned Spinach and Seasoned Broccoli
      • Dessert: Caramel Flavored Apple Pie and Mixed Fruit and Berry

 

Features and Benefits

 

  • Convenient, just open, heat and serve
  • Can be easily shaped for appealing plate presentation
  • Consistent texture and reliable nutrition
  • Great for Emergency stock
  • 5 to 8 servings per can

Once opened, remaining portions can be stored immediately in an air-tight container for 5 – 7 days in the refrigerator or placed in the freezer for up to one year. For quality assurance, unopened products should be consumed within two years of being manufactured, which is determined by the number on the bottom of the can.  For assistance with reading the Julian code, please visit our frequently asked questions.

 Thick-It® Purees may be covered by Medicaid providers and insurance companies.  Contact your or your loved one’s insurance provider to see if they will cover the Thick-It® Purees, as some may cover the expenses associated with swallowing disorders. Visit our frequently asked questions page to learn more about HCPCS codes, which are used for billing insurance purposes.

Today, I received several samples of Thick-it.  Pasta, frozen meats, vegetables and fruits in molded trays and several cans of food.  The box was huge and heavy with a large thermo container for the frozen foods with dry ice, which my kids thought was the coolest thing when my husband dumped it in the sink in the bathroom.

I opened the first can of Thick It food, which was Berry Fruit Puree.  It was actually good, tasting like flavored applesauce.  My 8 year-old, very picky daughter loved it.

The frozen pureeds in the molds took close to an hour and a half for the meats to cook in the oven, a little less for the fruits and vegetables.  I tried the berry, peaches, corn, green beans, chicken, turkey, ham and roast pork.  These are made to look like the actual foods after cooking and turning over and dumping on the plate.  The corn was good.  The peaches and berries were ok, but very gel textured.  The meat, I couldn’t eat.  It was very fake tasting and just over-powering and gritty.  The green beans were bland.  The only foods that kept that shape of the molds were the corn and meats.

My husband stated the meats tasted very gritty and the ham was a very fake, smoky taste that he didn’t much like.   He liked the corn and the taste of the fruits, but not the gel texture of the fruits.  The chicken and turkey he thought were bland but not as bad tasting as the ham and the green beans did not taste like green beans at all.

I couldn’t eat the canned foods.  Not only did it look like something I would feed my dogs, it smelled the same.  I took a small bite and food was either very bland or tasted nothing like what it was supposed to taste.

My husband, didn’t mind the canned pureed corn and green beans, just thought they were a little flavorless, but the canned lasagna and seasoned chicken tasted nothing like they were supposed to taste.

I commend Thick-It though on a good effort.  It seems they’re on the right track, just some of the food needs some work.

I did have the opportunity to not only meet, but sample Pure-A foods at ASHA 12 in Atlanta, GA.  I tried the taco and cheesecake at that time.  It was actually not bad.  The cheesecake was very good.  The taco looked like pureed food, but tasted surprisingly like a taco.

The Pure-a website offers a list of advantages of their products:

PURE A ADVANTAGES

Pure-a meal components have many advantages over frozen options. Below is a brief list of the many benefits Pure-a offers vs frozen.

Pure-a items can make both pureed meals and shakes (Nectar/ Honey Like Consistencies). Just follow the simple directions, in addition, you can make ice cream from Pure-a desserts.   

Pureed products use flavorful, dried ingredients. Dried ingredients are used in many of your favorite foods to help boost flavor. They offer great taste, color and aroma while maintaining nutrition. In addition, our products are made wth all natural flavors. Pure-a can afford to use better ingredients because of the shipping savings realized by not shipping water.

Pure-a products are less expensive. Compare the delivered cost of Pure-a products vs frozen products. Because frozen shipping is so expensive, you can save almost $2.00 per unit on a 3 oz protein item by using Pure-a vs frozen options.

Pure-a products are safe, the drying process sterilizes the food, making it safe to eat even if it is not prepared properly. Many frozen items must be heated to 165 degrees in order to be sterilized and safe to eat. In addition, frozen items can thaw during shipping if not handled properly.

Pure-a products are shelf stable, which allows for inexpensive shipping and storage. The savings from shipping can be over $1.00 per 3 oz serving. In addition, you can store Pure-a items in your pantry and do not need to buy and run an expensive second freezer.

Pure-a products are easy to prepare. All you need to do is pour the powder into a bowl, add water, whisk and let sit for 1 minute. No need to use a microwave, oven or steamer which frozen products require.

Pure-a products are better for the environment. Pure-a products do not require significant packaging such as dry ice or gel packs to keep the product frozen.

I sampled several of the Pure-A foods when I received samples for a patient.  Grilled asparagus, fiesta taco, cheesecake, baked mac and cheese.  Pure-A comes in a small pouch and is shipped in powder form.  The box you receive for a variety of packets is small.  It is mixed with hot boiling water/liquid and cold water for most of the desserts.

The Pure-A food was actually fairly good.  It tasted like a taco or cheesecake filling.  It is a little gritty, but I can get used to that given the exceptional taste.   The vegetables were not bland and the dessert was enjoyable.  The only downside for Pure-A is the smaller selection of food.  I am very excited to see the new foods the Pure-A company develops as they continue to grow.

**UPDATE**  Today, I received 14 samples of Pure-a in the mail.  I tried all of them.  The food continues to be very good.  The only foods I really didn’t like were the spaghetti, sweet and sour chicken and the asparagus.  Other than that, the food was really good and I could tell what it was supposed to be.

My husband wasn’t able to sample the Pure-a, however a pediatric patient really liked the foods and his caregiver was excited at the small size of the packaging and the ease of the preparation.  She also stated the food was actually pretty good.

Thick It offers 6 different entrees (Beef in Barbecue Sauce, Beef Lasagna, Beef Stew, Chicken a la King, Salisbury Steak, and Seasoned Chicken Patty), 2 breakfast items (Maple Cinnamon French Toast, Omelet with Sausage and Cheddar Cheese), 5 side items ( Carrot & Pea, Seasoned Green Bean, Sweet Corn, Seasoned Spinach and Seasoned Broccoli) and 2 desserts ( Caramel Flavored Apple Pie and Mixed Fruit and Berry).  Pure-A offers 9 entrees (Turkey/Mashed Potatoes & Gravy, BBQ Beef and Southern Corn Bread, Italian Spaghetti with Fennel, Fiesta Beef Taco and Corn Tortilla, Sweet and Sour Chicken, Roast Beef/Mashed Potatoes and Gravy, Baked Mac and Cheese, Chicken Parmesan, Teriyaki Beef Bowl), 7 sides (Sauted Spinach and Mushrooms, Fully Loaded Baked Potato, Autumn Harvest Sweet Potato, Creole  Corn and Tomatoes, Grilled Asparagus, Green Bean and Tomato Salad, Almond Seasoned Green Beans) and 5 desserts (New York Style Cheesecake, Blueberry Cobbler, Strawberry Shortcake, Georgia Peach Cobbler, Banana Cream Pie).

Both companies also offer samples, so that you or your patients can try these products prior to purchasing large amounts.

The cost comparison from Pure-a states costs as follows:

Save almost $2.00 per unit vs frozen options with Pure-a!

Pure-a meal components offer restaurant quality flavor and aroma at a lower delivered price than frozen options. Because Pure-a meal components are shelf stable, they do not require frozen shipping allowing Pure-a to use better, all natural flavors. In addition to saving on your purchase, you will not need to take up valuable frozen storage space or run an expensive second freezer.

See for yourself how much you can save with Pure-a. Below is an example showing the price for 24 units of Roasted Turkey. Pure-a allows you to save almost $2.00 per unit vs some frozen options.

Pure-a Frozen Option #1 Frozen Option #2
Price per unit $2.99 $3.99 $3.45
Price for 24 units $71.76 $95.76 $82.80
Shipping $12.00 $59.54 $50.00
Delivered Price $83.76 $155.30 $132.80
Delivered Price per unit $3.49 $6.47 $5.53

One concern with both Thick-It and Pure-a is this.  My husband and I have recently completely revamped the way we eat.  We have stopped eating salt, high fructose corn syrup, corn starch, wheat, basically we eat very fresh food.  I would love to see both companies strive to create an alternative for those health-conscious people that don’t want preservatives, salt or gluten, however want a quick and easy fix for pureed.  That might not be possible with the packaging, but would be a great advantage for any company!

I highly recommend that you request samples to try this for yourself.

I will still say, if any of you reading this are my SLP someday, please don’t put me on a pureed diet.  However, I think I could actually eat some of the pre-made from Thick-It and all from Pure-a.

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Using your iPad in Dysphagia Therapy

Using Devices with Dysphagia

Let’s Get Techy

So many people are using iPads, iPhones and iPods in therapy. While there are many other devices out there, I’m focusing on the i devices because those are the devices that I know the best. It is very easy to find apps for pediatric speech therapy, even apps for adult language therapy. There are apps for language, articulation, AAC, voice, fluency, and a few for dysphagia, but not many. It seems that few therapists are using their devices for dysphagia therapy. In lieu of the small amount of apps available for those of us specializing in dysphagia therapy, we can very effectively use our devices for treatment.

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