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Intensive Dysphagia Rehabilitation (IDR)

IDR

Dysphagia Rehabilitation

Over the past 15-20 our efforts in the treatment of dysphagia have moved from compensation and management to rehabilitation.

We know that through the principles of neuroplasticity that swallowing is the best way to have the patient rehabilitate the swallow.   Having the patient swallow challenging bolus types or swallow without the use of compensation (chin tuck) can challenge the swallow.   We can add resistance through a more challenging bolus for the patient or we can add weight to the bolus by having the patient swallow a thicker bolus (honey thick liquids as a therapy task only, even if the patient is on a thinner consistency).

Malandraki and Hutcheson 2018 stated that single intervention regimens may be inadequate to rehabilitate the complex swallowing deficits seen in patients with moderate-severe or persistent dysphagia.  Protocols have the potential to standardize clinical methods and to maximize patient outcomes.   Patients are anecdotally often less adherent when asked to complete too many therapies or long lists of exercises.   Protocols help clinicians plan personalized therapies integrating both skill and strength.

Usual Care

In a survey of Speech Language Pathologists (SLPs) that are members of SIG 13, Carnaby et al found that of the 254 SLPs that responded, there were:

  • 47 different interventions recommended
  • 3.9% chose recommendations based on physiological deficits
  • No single combination of therapies was repeated exactly
  • 58% of recommendations did not match the specific dysphagia symptoms

Even a protocol will have to allow for individualization for the patient.

Intensive Dysphagia Rehabilitation

The Intensive Dysphagia Rehabilitation program (IDR) was developed in 2013 and published in 2016 by Malandraki, et al.   IDR is a comprehensive and intensive rehabilitation approach based on the principles of neuroplasticity and exercise physiology with specific integration of adherence-inducing features.

IDR:

  • Maximizes patient outcomes
  • Patients with moderate-severe neurogenic dysphagia
  • Patient seen 2x/week in the clinic (Monday/Thursday or Tuesday/Friday) for 60 minutes with a home program daily (3x/day for 45-60 minutes/day)
  • Usually 4, 8 or 12 weeks

Assessment

First up in IDR is a comprehensive swallowing assessment to determine if the patient is a candidate.   You first want to get a complete medical history including:

  • Prior and current medical treatments and medication
  • Current health, nutrition and respiratory status
  • Existing social support system
  • Patient preference for foods, liquids, sweets, flavors, mealtime routines
  • Open interview-what are the patient and caregiver goals for therapy

A Clinical Swallowing Evaluation (CSE) is completed including assessment of oropharyngeal sensorimotor assessment, cranial nerve assessment, sensory perception and motor integrity (muscle tone, strength, ROM, speed, accuracy, reflexes) of muscles and structures in swallowing (using IOPI, Respiratory Pressure Meter).

The CSE is followed by an instrumental assessment, either VFSS or FEES, however VFSS is preferred.

Cognitive screening is completed using the Montreal Cognitive Assessment (MOCA) or the Cognitive Linguistic Quick Test (CLQT).  Cognition is assessed as IDR requires a basic understanding of several steps and components.   IDR has been successful with patients with normal or mildly impaired cognition.

Quality of life is assessed using the Swallowing Quality of Life Survey (Swal-Qol) and the patient is also assessed using the Beck Depression Inventory.

3 Components

There are 3 components to IDR.

Daily Evidence-Based Oropharyngeal Training– increasing gradually based on exercise physiology guidelines.

Two evidence-based exercises are selected and completed on alternating days.   This allows for muscle rest and recovery and helps to sustain patient motivation.   The intensity of the exercises increase biweekly based on exercise physiology principles.   Each exercise should target different muscle groups (lingal , pharyngeal, suprahyoid) or different neuromuscular goals (strength vs. coordination).   You can read more about exercise principles.

Evidence-based exercises include:

  • Lingual strengthening
  • Effortful Swallowing
  • Mendelsohn Maneuver
  • Shaker

Exercises are chosen based on:

  • Underlying pathophysiology
  • Ability to perform exercises
  • General health
  • Cognitive status

Daily Targeted Swallowing Practice (TSP)– which increases gradually in complexity following the principles of experience-dependent brain plasticity

This is where you challenge the swallow with a bolus.   You can advance or downgrade what you are presenting the patient determined by the patient’s performance and health status.

Small sets of single swallows of materials identified during the instrumental assessment are used.   Use textures/viscosities that are observed to be difficult but relatively manageable with the use of compensatory strategies.   With TSP, you are continually having the patient use the swallowing mechanism and the central/peripheral neural circuits engaged in swallowing.

Adherence Inducing Features

We know that patients are more likely to complete 1 exercise per day, that they understand because you explain what the 2 chosen exercises do, rather completing a long list of seemingly meaningless exercises daily.

Why does IDR feature to increase adherence?

  • Shown to improve exercise and treatment adherence.
  • Salience, socal support, simple health literacy.
  • Patient chooses flavors of the challenge swallows.
  • Salience enhances experience-dependent neuroplasticity.
  • Caregiver becomes the coach at home.

What does the research tell us?

Malandraki, et al 2016:

10 patients, 4 weeks

Penetration Aspiration Scores (PAS) improved

Maximal lingual isometric pressures increased.

EAT-10 (QOL measure) increased.

ASHA NOMS improved (level of oral intake) with less restrictive diet

4 patients remained on restricted diets indicating that 4 weeks may not have been enough for them.

If you want a little more information, the Malandraki & Hutcheson 2018 paper outlines the complete IDR program along with the MD Anderson BootCamp program (which I will outline here on the blog next).

References:

Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: A survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567-574.

Malandraki, G. A., & Hutcheson, K. A. (2018). Intensive therapies for dysphagia: implementation of the intensive dysphagia rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. Perspectives of the ASHA Special Interest Groups, 3(13), 133-145.

Malandraki, G. A., Rajappa, A., Kantarcigil, C., Wagner, E., Ivey, C., & Youse, K. (2016). The intensive dysphagia rehabilitation approach applied to patients with neurogenic dysphagia: a case series design study. Archives of Physical Medicine and Rehabilitation, 97(4), 567-574.

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IDDSI

The International Dysphagia Diet Standardisation Initiation is here and being utilized in many facilities.

IDDSI was created to replace the National Dysphagia Diet and to standardize food and liquid consistencies.

I’m sure you have probably been in a number of facilities that interpret Mechanical Soft, Dysphagia Soft, etc a little different than other facilities.   Some facilities allow a number of food items on one diet level that another facility adds into a different level.

IDDSI

IDDSI involves 5 food consistency levels and 5 liquid levels.

So what do these levels mean?

Level 0 (Thin) is a liquid that flows like water.   (Flow test 1 ml or less in the syringe.)

Level 1 (Slightly Thick) Thicker than water, but is not quite Mildly Thick (formerly Nectar Thick).   (Flow test 1-4 ml remains in syringe).   This may include formula or commercially available nutrition drinks such as Boost or Ensure.

Level 2 (Mildly Thick formerly Nectar Thick).   Flows off a spoon but is thicker than water.   Requires increased effort to drink from a straw.   (Flow test 4-8 ml left in the syringe.)

Level 3 (Moderately Thick formerly Honey Thick).  This level takes a moderate effort to drink through a straw, but can be drunk from a cup.   This level can be taken from a spoon, but is too thin for a fork.   (Flow test 8-10 ml left in the syringe.)

Level 4 (Pureed/Extremely Thick formerly Pudding Thick).  Usually can be administered via spoon, however may also be eaten via fork.  Cannot be taken through a straw, usually taken via spoon.   There should be no lumps, requires no chewing and the liquid should not separate.   (Flow Test 10 ml remains in the syringe.)   Spoon tilt test-should fall off the spoon in single spoonful.   Should sit in a mound on top of the spoon/fork with minimal dripping through the fork.

Level 5 (Minced and Moist) Small lumps in the bolus (no larger than 4mm width and 15mm length for adults), can be eaten using spoon or fork.   Liquid should not separate from food.   (Fork test minimal pressure to mash with no blanching of the thumbnail  to white while pressing.)  (Spoon test should fall off the spoon in a cohesive mound with little to none left on the spoon.)

Level 6 (Soft and Bite Sized) Can be eaten with a fork, spoon or chopsticks.   Each piece should be no larger than 15mm.   Chewing is required with this consistency, however biting or cutting is not required.   (Fork test, when a fork is pressed against the food, the thumbnail should blanch or turn white to squash or break apart the food).   (Spoon test pressure from the spoon can cut, squish, mash or break apart the food and it will not return to its shape.)

Level 7 (Easy to Chew) Normal, everyday soft foods.   Size of food is not restricted.   Requires the ability to bite/chew food.   (Fork/Spoon Test food is easily cut with pressure from a fork/spoon, thumbnail blanches or turns white when applying pressure to the food until it smashes, breaks apart or crumbles without resuming its original shape.

Level 7 (Regular) Normal, everyday food.

Transitional Foods (Fork/Spoon test, add 1 ml water, wait 1 minute, when applying pressure on the fork/spoon on the food, thumbnail blanches while applying pressure until the food breaks or smashes.)

Some examples of transitional foods?

Ice chips
Ice cream/Sherbet if assessed as suitable by a Dysphagia specialist
Japanese Dysphagia Training Jelly sliced 1 mm x 15 mm
Wafers (also includes Religious Communion wafer)
Waffle cones used to hold ice cream
Some biscuits/ cookies/ crackers
Some potato crisps – only ones made or formed from mashed potato (e.g. Pringles)
Shortbread
Prawn crisps
Veggie Stix™
Cheeto Puffs™
Rice Puffs™
Baby Mum Mums™
Gerber Graduate Puffs™

For everything you need to know regarding IDDSI, visit the website here.

Do you want easily printable information sheets for each level and testing for each level?    Find that here.

Want samples and examples for testing liquids/foods?   Find that here.

Evidence supporting IDDSI can be found here.

IDDSI documentation has been translated in multiple languages that you can download here.

Available languages:

  • Chinese
  • Farsi
  • French
  • German
  • Greek
  • Italian
  • Norwegian
  • Portuguese
  • Spanish
  • Swahili

Need help with implementation of IDDSI into your facility?   You can download documents here.

 

 

 

Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.

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Carbonated Beverages

Carbonation

Not Nectar Thick

When patients have dysphagia, often sensory techniques, including carbonation can help increase aspects of the swallow.  For some reason, at one point in time, the research was translated to substitution of carbonated beverages, including soda to replace nectar thick liquids.

 

carbonated

Continue reading Carbonated Beverages

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The Patient Exercising Their Right to Choose (Formerly The Non Compliant Patient)

 

EDIT 1/4/17.  Due to a recent Facebook post, I wanted to change some wording on this post.  As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.

Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”  

There was post recently on the Special Interest Group (SIG) 13 email blast.  An SLP was asking what to do with a noncompliant patient.

When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged.  The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.

My belief system is not the same, fortunately for my patients!

First, think about this.  Aren’t the noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about?  The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make.  They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe.  The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety.  That is the patient that may be most at risk for aspiration pneumonia.

In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity.  I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.

The best thing we can do for our noncompliant patients is to educate and rehabilitate.  Why not make them safer with the consistency they choose?

The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care.  If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow.  I recently wrote a post about oral care which you can find here.

It’s important to remember that we want the patient to succeed with the diet they choose to consume.  We can recommend a safe diet and we can advise but we have to focus on the rehabilitation.  Just remember, not everybody that aspirates develops aspiration pneumonia.  There are functional aspirators.

You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia.  Just because that patient does not choose the diet you recommend does not mean you give up on them.  If they are willing to put in the work and give you some time (they will have to buy-in to your program)  THOSE are absolutely  patients with whom we should work.

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Swallowing and Dysphagia Rehabilitation: Translating Principles of Neural Plasticity into Clinically Oriented Evidence

Robbins J, Butler SG, Daniels SK, Gross RD, Langmore S, Lazarus CL, Martin-Harris B, McCabe D, Musson N, Rosenbek JC.  (2008).  Swallowing and Dysphagia Rehabilitation:  Translating Principles of Neural Plasticity into Clinically Oriented Evidence.  Journal of Speech, Language, and Hearing Research, 51: S276-S300.  

This article breaks down the principles of neural plasticity.   Neural plasticity is defined as “the ability of the brain to change.”  Central Nervous System Plasticity refers to “the ability of neuronal systems to alter functino in response to changes in input, both physiological and pathophysiological.”  One thing the authors warn is that just because neural plasticity may result in a behavioral change, not all behavioral change results in neural plasticity.

There are 10 basic principles of neural plasticity.  They are:

1.) Use It or Lose It

2.) Use It and Improve It

3.) Plasticity is Experience Specific (Swallow to Improve Swallowing)

4.) Repetition Matters (How many times you repeat an exercise)

5.) Intensity Matters (Longer training does not necessarily imply more difficult training)

6.) Time Matters (Time after incident)

7.)  Salience Matters (Purposeful movement related to the behavior being trained)

8.)  Age Matters (Younger brains are more responsive, but plasticity occurs across the life span)

9.) Transference (“The ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity” such as LSVT or EMST)

10.) Interference (“the ability of plasticity within a neural circuitry to impede the induction of new or expression of existing, plasticity within the same circuitry”)

Techniques, compensations, maneuvers and exercises we have our patients use were broken down into 4 groups.  Sensory Methods, Compensatory Methods, Motor with Swallow and Motor without Swallow.

The following is adapted from charts the authors created demonstrating behavioral vs. neural change within each group.

Sensory Methods: (From the literature)

Bolus Effects                                                                        Behavioral                                            Neural

Volume                                                                                   Yes                                                             No

Viscosity                                                                                 Yes                                                             No

Temperature                                                                        Yes                                                            No

Taste Enhancement                                                         Yes                                                             No

Stimulation

Thermal-Tactile Stimulation                                      Yes                                                              Yes

E-Stim                                                                                      Yes                                                              Yes

DPNS                                                                                         No                                                              No

Occluding Trach                                                                 Yes                                                             No

Visual Feedback                                                                 Yes                                                             No

Compensatory Methods: (From the literature)

Chin Tuck                                                                               Yes                                                             No

Head Rotation                                                                     Yes                                                              No

Head Tilt                                                                                 Yes                                                             No

Head Back                                                                               No                                                             No

Side Lying                                                                                Yes                                                             No

Breath Hold                                                                             Yes                                                           No

Bolus Consistency                                                              Yes                                                            No

Motor with Swallow:  (From the Literature)

Mendelsohn*                                                                           Yes                                                            No

Super Supraglottic                                                             Yes                                                            No

Supraglottic                                                                            Yes                                                            No

Effortful Swallow *                                                                 Yes                                                            No

Tongue Hold *                                                                          Yes                                                            No

Swallow (Frequency)                                                          Yes                                                            No

(* has the potential for plasticity)

Motor without Swallow:  (From the Literature)

ROM                                                                                               Yes                                                          No

Strengthening-Tongue*                                                      Yes                                                          No

Strengthening-Respiratory *                                            Yes                                                          No

Tongue Control                                                                       Yes                                                            No

Shaker *                                                                                        Yes                                                             No

LSVT  *                                                                                           Yes                                                              No

Pharyngeal Exercises*                                                           No                                                               No

Gargling                                                                                         No                                                               No

Vocal Exercises                                                                           No                                                               No

Velar Elevation                                                                            No                                                               No

Airway Closure/Breath Hold                                              Yes                                                               No

So, some of the techniques, compensations and exercises we use do create a behavioral change, including increased airway protection to reduce or eliminate penetration/aspiration, better control of the bolus, etc.  Few cause an actual neural change.

Looking at each principle and each category the authors created a great table which I will summarize.  Looking at 5 categories 1.) Sensory Methods Bolus Effects 2.) Sensory Methods Stimulation 3.) Compensatory 4.) Motor with Swallow  5.) Motor without Swallow:

1.) Meets all 10 principles, with a question on Time Matters

2.)  Meets all 10 principles with a question on Time Matters

3.)  Meets all 10 Principles, however questioning interference.

4.)  Meets all 10 principles except interference

5.)  Meets all 10 principles except Salience Matters

There are many areas that continue to warrant research in the field of dysphagia.  One thing we need to keep in mind that the authors point out:  “the primary role of swallowing rehabilitation is to effect change (i.e. improved strength, duration and timing of movement) in the physiologic components of swallowing, which will have a direct influence on bolus flow kinematics through the aerodigestive tract.”  Also “The immediate lesson for the swallowing clinician, however, is that training-even the training of a patient who is aspirating and at high risk for pulmonary or other health consequences-appears preferable to merely observing and documenting.”

Whether we’re using dry swallows or bolus swallows with our patient, we need to keep them swallowing.

I absolutely think this article is a MUST read for any dysphagia therapist.

Of course, after writing this article, I realized, I already blogged about it!   Talk about needing some plasticity for memory skills!!!  So, I will also post the original blog here as well!

Neural plasticity refers to the ability of the brain to change.

The 10 principles of plasticity are 1.) Use it or lose it, 2.) Use it and improve it, 3.) Plasticity is experience specific, 4.) Repetition Matters, 5.) Intensity matters, 6.) Time matters, 7.) Salience matters, 8.) Age matters, 9.) Transference and 10.)Interference.

For principle 1, Use it or Lose it, the simple act of swallowing will not improve the swallow in a person with dysphagia. They need to use the function with increasing competence. The question remains what are the best treatment strategies for swallowing. It makes sense that those patients that are NPO and have not swallowed in years will “lose” their swallow function. Simple saliva swallowing drills can help a person return to oral feedings.

Principle 2, Use it and improve it, there are many different treatment techniques including expiratory muscle strength training, lingual strengthening, Shaker, Mendelsohn, Masako and effortful swallow. Keep your patients swallowing to strengthen those muscles, but as they swallow, challenge the patient and challenge the swallow system. To merely sit and observe as a patient eats a meal is by no means therapeutic. To feed a patient during a meal is by no means therapeutic. Building the competence of a system is imperative, not just allowing a patient to complete the simple act of swallowing.

Principle 3, Plasticity is experience specific, to focus and rehab the swallow may or may not affect other aspects, such as dysarthria or voice deficits and vice versa. Does simply completing OME with patients improve the swallow?? If we have the patient complete voice exercises, that do not involve the swallow, how will that improve the swallow function. It’s a different function to complete the exercises without a bolus than it is with a bolus. 

Principle 4, Repetition matters, number of repetitions of an exercise will affect the neural changes made by that exercise. Many of the effective exercises involve systematic repetition such as LSVT, isometric lingual exercises and the Shaker. Simply completing a movement or an exercise 10 times 3 times a day may not cut it. The Shaker uses 90 repetitions and 3 repetitions of holding the head up and seems far more effective than simple OME alone. 

Principle 5, Intensity matters, there is building evidence that intensity is critical for swallowing therapy. Evidence is still pending for particular dosage recommendations that are therapeutic for the swallow. If you are training for a fight, to run, to lift weights, etc, how can you improve without an intense workout. We’re working with a muscular system with swallowing and should apply the same exercise science rules to swallowing as we do to any other training.

Principle 6, time matters involves the length of your session. A person is going to benefit more from a longer session, 30-60 minutes then they will a 15 minute session. 

Principle 7, Salience matters, therapy has to be purposeful for swallowing. You can’t have the person stick out their tongues 15 times and expect their swalow to improve. Simple, repetitive movements and strength training are likely not going to improve swallow function.

Principle 8, Age matters, although neural plasticity does occur throughout the lifespan, a younger system will be more responsive to the changes. This may imply that older adults need a more strenuous or a program with a greater length of time.

Principle 9, transference defined as “the ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity.” Evidence from NMES (neuro muscular electrical stimulation) applies to this principle. This continues to be a principle that needs further investigation for implications to the swallowing system.

Principle 10, interference results from inappropriate use of E-stim. E-stim can either facilitate or inhibit the corticobulbar excitability. A simple change in Hz can change the excitability which is why there is extensive study out there now on NMES.

These principles can and should be incorporated into therapy. The more a therapist understands the swallowing system, exercise physiology and neural plasticity, the better prepared they are to treat a dysphagic patient.

Bonnie Martin-Harris and colleagues found 14 physiologic components in the swallowing system,
~lip closure
~hold position/tongue control
~bolus preparation/mastication
~bolus transport/lingual motion
~initiation of pharyngeal swallow
~soft palate elevation and retraction
~laryngeal elevation
~anterior hyoid excursion
~laryngeal closure
~pharyngeal stripping wave
~pharyngeal contraction
~pharyngoesophageal segment opening
~tongue base retraction
~esophageal clearance

Our role as a therapist is to improve the strength, duration and timing of the swallowing movements, with regards to the above components.

We have different options with different interventions including bolus effects by altering volume, viscosity, thermal, taste, tactile or temperature. We can use e-stim. Compensatory strategies including the chin tuck, head rotation, head tilt, head back and side lying positions. We can use maneuvers such as the Mendelsohn, Supraglottic swallow, Super Supraglottic swallow, effortful swallow, double swallow or the Masako. We also use lingual exercises and the Shaker. 

The Mendelsohn can alter the extent and duration UES opening as well as aiding in hyolaryngeal excursion.

The supraglottic and super supraglottic swallows facilitate the timing and extent of laryngeal closure at specific levels of the larynx.

The effortful swallow help to increase base-of-tongue retraction and results in increased tongue propulsive force, increased oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, longer duration of pharyngeal pressure and UES relaxation.

The tongue hold maneuver increases anterior motion of the posterior pharyngeal wall at the level of the tongue base.

You can find increased tongue base-pharyngeal wall pressure and contact duration when performing the effortful swallow, tongue-hold, Mendelsohn and super supraglottic swallow.

Robbins and her group demonstrated that lingual muscles have a propensity for increasing strength and mass and that as a result of non-swallowing exercises, improvement in swallowing pressures on liquid boluses occurred, penetraion Aspiration Scores were reduced and dysphagia-specific quality of life improved. 

The Shaker exercise increases swallowing function through decreased aspiration following the swallow. 

There is still a need for research from this article including looking at variables of repetition, intensity and time for rehabilitation and finding the appropriate site, stimulation frequency, amplitude, phase duration, optimal frequency and length of an individual stimulation treatment including potential effects.

When presented with a patient with dysphagia, research the disorder. If you are requesting an MBSS ask that the therapist look at muscle movement rather than just the absence or presence of aspiration/penetration. Treat the system as a whole and as a muscular system. We can actually learn much from our PT and OT friends on exercise physiology and use that to design our dysphagia therapy programs to better serve our patients.

Article and references can be found at: http://jslhr.asha.org/cgi/content/full/51/1/S276.