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Exercise

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 rehabilitation93(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

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Modified Barium Swallow Study……Part 2

I was recently directed to a blog post by Clinical Colleagues Confidential. regarding Modified Barium Swallow Studies (MBSS).

 The title of the blog post is:

 I have all the answers but nobody is asking me any questions

The original blog post can be found at:  http://cccslp.net/whats-the-frequency-3/

 This is part 2, because I recently wrote a post about MBSS.

 Being an SLP that actually completes MBSS, I felt I needed to address some of these issues comments.

1) I stopped the MBS because I was afraid the patient would aspirate.  Patients aspirate……it happens.  They have probably been aspirating for a long time prior to your study.  If you are afraid of aspiration, how can you assess the patient’s true swallow function?

2) The patient was coughing so I changed him to pudding at bedside.  Patients cough.  You need to check the patient’s meds (some actually cause a cough) and trial a consistency more than once to determine if the consistency is causing the cough.  It is also helpful if you use an instrumental exam such as FEES or MBSS to determine the physiology of the swallow.

3) I didn’t try thin during the MBS because at the nursing home he was already on nectar so I started there.  I use the protocol employed by the MBSImP.  Thin is tested.  I don’t stray from my consistencies.  I use thin, nectar, pureed and cookie with every patient (unless there is a very valid reason to not do a certain consistency).

There are many pieces of information you can use when you assess thin that you don’t get from nectar.  That’s why I don’t skip it.

4) There’s no speech at nursing homes so I put her on the safest diet; puree and pudding thick.  Who says that pureed and pudding thick is the safest.  Sometimes thick is not necessarily better.  Many people eat safely, millions in fact without the presence of speech.  You should not punish your patient because of lack of SLP.

5) A suspected timing delay of the epiglottis might be present and could lead to aspiration even though none was apparent on the MBS but to be safe I recommend nectar thick liquids.  If you did the MBSS, you should know if there is a delay of the epiglottis or not.  You SHOULD be assessing the epiglottis.  You should also know that epiglottic movement is indicative of hyolaryngeal excursion.  Sometimes you don’t see aspiration on the MBSS but you should be looking at airway protection and hyolaryngeal excursion which is an indicator.

 6) I didn’t want to recommend something they might aspirate and get sued.

I wish there was no number 6. Sadly, I think it is the driving force behind many of the recommendations. But, I would spread some words of caution to my peers, especially the younger ones. The only thing that avoids litigation is luck. The thing that wins litigation is expertise and documentation.

If you make a swallowing recommendation in isolation of the needs of whole patient to save him from aspiration pneumonia and he goes into renal failure…that’s a big problem.  I agree….documentation is key.  If you document that the patient appears safe, that is your finding.  You should be confident in your skills and you should be effective in your skills in completing MBSS.  This is not an area we can make a mistake because that can put your patient at high risk for pneumonia, respiratory issues, maybe death.  You recommend what’s appropriate for that patient without worry about litigation.

We seriously need to take a look at our profession.  WE are the experts in dysphagia.  We need to demonstrate our skills as experts.  Dysphagia is not an area we can “tinker” in.  

I highly recommend that any SLP completing MBSS that has made any of the above statements, take the Modified Barium Swallow Impairment Profile (MBSImP) by Bonnie Martin Harris.  This is becoming the gold standard for standardization of modifieds.  

Our responsibility as SLPs completing MBSS is to determine the physiology and etiology of the swallow/dysphagia.  We need to determine what is functioning and what is not functioning in the oropharyngeal mechanism.  Our job is not to state aspiration or penetration or….I coulnd’t do that because I was scared of this.  Our job is to state epiglottic dysfunction, lingual dysfunction, decreased laryngeal elevation, decreased arytenoid movement, and so on.  

SLPs need to take a stand and become experts in the area of dysphagia.

 

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Dysphagia Assessment

Assessing Dysphagia

Always the same……

So many people assess dysphagia in the same manner, at least from my observations. Sit with them while they eat a meal, feel laryngeal elevation and trial diet modifications. I have rarely watched SLPs complete a thorough dysphagia bedside evaluation.  There is no standardization of the Clinical Swallow Evaluation (CSE) 

Thorough Chart Review

Every evaluation should include a thorough chart review.   What complaints does the patient have?  What is the reason for hospitalization?   Why do they need a speech evaluation?

You will want to ensure that the patient actually has an order for speech.   You also want to check past medical history, what contributing diagnoses are there for dysphagia, if there is a history of swallowing difficulty.   You want to look at medications, lab results, xray results.   Any of this information can be critical in your diagnosis of dysphagia.

If the person has had a stroke, you want to find as much information as possible on the stroke.   If the person has head and neck cancer you want to know where the tumor is and the tumor grade.   You want to know the course of treatment, if there was surgery, chemotherapy, radiation including how much and what kind.

Standardized Assessment

I have worked to standardize the manner in which I complete my Clinical Swallowing Evaluation. I have started using the SOPE, the MASA, the EAT-10 and the OHAT during every assessment, along with a thorough chart review and assessing dysphagia risk factors.  There are many other outcome measures available out there as well.   You can find an entire list of outcome measures with links!

I can complete a fairly thorough assessment. The SOPE assesses cranial nerves, taste buds and some muscle function. The OHAT assesses oral cleanliness and need for oral care. The MASA has been a fairly accurate indicator of dysphagia and aspiration.   The EAT-10 is a self-assessment tool that the patient can complete.

The Yale Swallow Protocol is a screening tool that can be used by nursing staff and the SLP to determine a need for further evaluation.  The Yale can be an indicator of aspiration, as it is believed, people that silently aspirate small amounts of liquid will choke with larger volumes. 3 ounces of water is enough to make a person choke, as it is stated per this protocol that silent aspiration is volume dependent. 

Cognition

It is important to look at cognition when you are evaluating dysphagia.   You don’t have to do a complete battery assessment, however you can look at the patient’s ability to answer yes/no questions, answer orientation questions and follow simple, 1 step commands.   Leder, Suiter and Warner found that patients that are not oriented x3 are 31% more likely to aspirate.   They also found that liquid aspiration is 57% more likely, puree aspiration is 48% more likely and the patient being deemed to be unsafe with any consistency is 69% more likely in patients that are unable to follow 1-step commands.

Cranial Nerves

It is important to assess cranial nerves and to understand the cranial nerves. For instance CN XII, the hypoglossal nerve has no sensory pathways, only motor. This definitely affects the means by which you will assess,  treat and write your report.

Another point that can drive your treatment protocol is that sensory input drives motor output. If you can increase the sensory input a person receives you can increase the motoric response.

Cranial nerve assessment is vital in understanding dysphagia. Sensory input such as olfactory and optical help to prepare the person for the swallow by increasing saliva and telling the body that it is going to masticate and swallow food/drink.  Changing taste, flavor, temperature, texture and size of bolus can influence a swallow.

Oral Care

You can actually tell a lot about a person by their oral hygiene. You can tell who will qualify for a Free Water Protocol. Also, by oral hygiene, you can make an assumption that the person is at higher risk for aspiration pneumonia because of the poor hygiene of the oral cavity. It is important to let nursing and nursing staff know how often to complete oral cavity for patients that are unable to complete this task with independence. 

Looking for more information on oral care?

Motor Function

It is necessary to assess motoric function. You treat the motor dysfunction, if present, not the symptoms, i.e. aspiration. If you assess a person and can only tell that they are aspirating, but not WHY they are aspirating, you are no better off than you were before the assessment.

There are many areas of function that are vital to swallowing, labial closure, lingual to palate contact, bolus management and propulsion (lingual strength), velar elevation, tongue base retraction, pharyngeal squeeze, hyolaryngeal excursion (laryngeal elevation, hyoid protraction and hyoid thyroid approximation) and UES opening. All of these are areas assessed through the MBSImP.

Observation 

Observation of a person eating a meal can also a part of  the evaluation. Observation of how a patient swallows pills, how many pills a patient takes, do they self-feed?  These can all be indications of aspiration pneumonia.   Observation should not compromise every treatment session with the patient.   

Writing the Report

When you write up your Clinical Swallow Evaluation, make sure you are thorough in your writing.   Include all of the observations.   You may want to include vital signs, if the person is on O2, how the O2 is presented and at what level.   How was the patient position, if they were being fed or able to self feed.   Include any information that is helping you to determine dysphagia.

Did You Answer All of Your Questions?

If, at the end of the CSE, you have not answered all questions about the person’s swallowing,  you will need to consider instrumental assessment, either Modified Barium Swallow Study or Flexible Endoscopic Evaluation of Swallowing.   Either of these assessments will help to give you more information on the patient’s swallow.

A Thorough Evaluation

A thorough dysphagia exam is vital and necessary for treatment. A good Clinical Swallowing Examination with instrumental assessment will aid you in accurate assessment for thorough and appropriate treatment for dysphagia.

References:

Leder, S..B., Suiter, D.M., & Warner, H.L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status.  Dysphagia, 24(3), 290-295.

Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia17(4), 298-307.

Martin-Harris B, Brodsky MB,  Michel Y,  Castell DO Schleicher D, et al.  MBS Measurement Tool for Swallow Impairment—MBSImp: Establishing a Standard.  Dysphagia, 2008, Volume 23, Number 4, Pages 392-405.

Suiter DM, Leder SB.  3 Ounces is All You Need.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia).  2009; 18(4):  111-116.

Logemann, J.A. (1998).  Evaluation and treatment of swallowing disorders (2nd ed).  Austin, TX: Pro-Ed.27 Wijting Y., Freed M. (2009).  Training Manual for the use of Neuromuscular Electrical Stimulation in the treatment of Dysphagia.

Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online.doi:10.1038/gimo8.

Coyle, J. L. (2015). The clinical evaluation: A necessary tool for the dysphagia sleuth. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)24(1), 18-25.

Langmore, S. E., Kenneth, S. M., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia2(4), 216-219.

Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia17(4), 298-307.

Leder, S. B., & Espinosa, J. F. (2002). Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing. Dysphagia17(3), 214-218.

Daniels, S. K., McAdam, C. P., Brailey, K., & Foundas, A. L. (1997). Clinical assessment of swallowing and prediction of dysphagia severity. American journal of speech-language pathology6(4), 17-24.

Garand, K. L., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment across the life span: The clinical swallow evaluation. American Journal of Speech-Language Pathology29(2S), 919-933.

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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.

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