MannaQure

                                                  






How Did I Ever Find MannaQure?

This always happens to me during the ASHA convention.  I get to a point that I am, well, maybe a bit silly and start Tweeting about crazy things.  This is the time that my following rises the most.

This year was no different.  As I was Tweeting various pictures of our friend Mary, I had a new follower called MannaQure.  Naturally, I was wondering what my Tweets had to do with my nails.

I first looked at the website.   MannaQure is a comprehensive dysphagia and dysarthria evaluation.  Not only is it an evaluation, but it is designed for Spanish speaking patients.

I was wondering about the name.  I couldn’t make the connection.  On the website, it states that:  “Manna”-Found in the book of Exodus, the food that was miraculously provided for the Israelites in the wilderness during their flight from Egypt. “Manna”-Mentioned in the bible, spiritual nourishment of divine origin. MannaQure is pronounced Manna.”


What Is MannaQure?


I found the MannaQure booth the next day in the exhibit hall.  The protocol for this evaluation has the questions/instructions written in English, in Spanish with pronunciation for those that do not speak Spanish and just in Spanish for those that are able to speak Spanish.  All on the same protocol.


It looked like a fairly comprehensive evaluation, with a few questions regarding cranial nerves.  I would love to have more time to look over this evaluation.


The complete set sells for $225.  The Examiner’s Manual alone is $125, 25 Questionnaires are $45 and 25 Protocols are $55.


If you work with Spanish Speaking patients, this may be an evaluation to look at.

Pudding and a Straw

                                                                                

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

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.

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.

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.   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.

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.

Now, 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.

Now, keep in mind, 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.

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.

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.

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

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.

G-Codes and Insurance and Rehab Optima…….Oh My!

I work in a critical access hospital.  I see patients in acute care, outpatients and do all MBSS in our facility.

 I am also the Rehab Director of our deparment.

 Our regional manager implemented G-Codes in our facility in early January.  We have been in-serviced on G-Codes and using them in our documentation.

 What are G-Codes?

 These are required codes when working with Medicare Part B patients.  There are 7 codes from which SLPs can choose to use with their patients.  These areas define the most relevant area with which we are working with our patient and must include an impairment modifier for each.

 ASHA offers information on G-Codes and has created a wonderful list of all the codes and modifiers here.  ASHA also recommends using ASHA NOMS which directly correlate with the impairment modifiers.

 The bottom line…..if you don’t use the G-Codes and Modifiers, you won’t get paid.  You can only use one code at a time although you can treat multiple impairments at one time.  (i.e., you may code for swallowing, however treat both dysphagia and expressive communication).

 ASHA offers an on-demand webinar explaining G-Codes for $99 for ASHA members and $129 for non-members.  The Specialty Board on Swallowing and Swallowing Disorders also offers a webinar by Nancy Swigert for $25.00.

 Insurance

 I don’t know how it is in other states, but here in Indiana, insurance has been a major roadblock for therapy.

 Medicaid often severely limits our sessions.  They will often give us 12 or 24 sessions.  When you have a patient that just had a stroke and is severely aphasic, 12 sessions at 2 times a week, 12 sessions at 1 time a week followed by a home program, typically does not cut it.  This is what we are allowed.

 Even if that patient has Medicare as a primary.  The Medicare is unlimited.  We are not under caps being a Critical Access Hospital.  Medicaid as a secondary limits the sessions because the patient cannot afford to pay the 20% out of pocket.

 BCBS typically gives us 20 sessions if they are primary, 60 sessions if they are secondary.  They will not pay for a cognitive therapy code if CVA is the primary medical diagnosis.  There is a list of diagnoses, small I might add, that I can use with specific codes for reimbursement.

 If you live in Indiana and have a stroke with BCBS as your insurance…..please don’t have cognitive issues only requiring cognitive therapy.  They won’t pay for that.

 I dread to see all the upcoming changes in therapy approvals for insurance with all the healthcare reform coming.  It has definitely changed to this point.

 Rehab Optima

 Our company primarily staffs nursing homes.  We have an acute care hospital contract for a critical access hospital.

 Our company recently switched from Casamba Smart to Rehab Optima.

 WOW

 Smart wasn’t necessarily functional for us, but RO is definitely not.  We have had nothing but issues since we started!!

 Hopefully it gets better!