Course Alert-Evidence Based Practice

critical_thinking_skills

Image from:http://thecollaboratory.wdfiles.com/local–files/philosophy-of-thought-and-logic-2011-2012/critical_thinking_skills.jpg

Northern Speech Services has a new course called:  Evidence-Based Practice In Adult Dysphagia Management: What The Evidence Says About Commonly Selected Rehabilitation Interventions.  This is a webinar by Ianessa Humbert, Catriona Steele and Phoebe Macrae.

I took this course over the weekend.  It was GREAT!  It starts with approximately 35 minutes of review of the anatomy and physiology by Dr. Humbert.  The second section is close to 2 hours and discusses 4 compensations/exercises including:  chin tuck, Mendelsohn Maneuver, Shaker and the Effortful Swallow.  Evidence for each of the 4 techniques is discussed and a look at critically appraising techniques/exercises for dysphagia.  A case study is provided for each.

This course only looks at 4 exercises/compensations, however it also breaks down the critical assessment for each, allowing the viewer to apply the same principle to any exercise/compensation.

I would definitely recommend this course to anyone working with patients with dysphagia.

Carbonated Beverages

carbonated

Carbonated beverages have hit the dysphagia world by storm.  Much of the recent dysphagia research has focused on the sensory portion of the swallow and how sensory drives the swallowing process.  Part of the sensory process is carbonated beverages.  One of the common misconceptions at this time is that carbonated beverages act as a nectar thick liquid.

Carbonation is a sensory option for dysphagia rehabilitation.   It’s effective through a process called chemesthesis, where the “bubbly” or “fizzy” of the carbonated beverage acts as a Trigeminal irritant.  The Trigeminal Nerve or Cranial Nerve V is one of the major swallowing nerves.  The Trigeminal Nerve has bare nerve endings making it more susceptible to sensory or afferent input.

Rather than acting as a nectar thick liquid, the carbonated beverage actually increases the sensory stimulation for the swallow.  Sensory input (afferent drive) drives the motoric output (efferent drive).

Research of carbonated beverages shows:

No significant effect on oral transit time, pharyngeal transit time, initiation of pharyngeal swallow or pharyngeal retention.  Carbonated beverages sis however decrease penetration/aspiraiton with 5 & 10 ml swallows.  (Saravou & Walshe).

Carbonated thin liquid significantly decreased the incidence of spillover, delayed pharyngeal response and laryngeal penetration compared to non-carbonated thin liquids.  (Newman et al).

Drinks containing chemical ingredients that activate sour and heat receptors alter swallowing physiology greater than water.  (Krival & Bates).

It is likely that sour and carbonated beverages reflect a more organized activation of the submental muscles because of more effective afferent input to the Nucleus Tractus Solitarius.  (Miura, et al).

One of the important issues to consider when looking at research involving carbonated beverages is that the researchers in these studies do not use Coke, Pepsi or Sprite.  They use Ginger Brew, Club Soda or carbonated citrus.

It is vital, as with any other compensation or technique to view the effects of carbonated beverages.  As with other strategies, you may not see the same effect in every patient and sometimes, the strategy you choose may make the swallow worse.

Krival K, Bates C. Effects of Club Soda and Ginger Brew on Linguapalatal Pressures in Healthy Swallowing. Dysphagia (2012). 27: 228-239.

Newman, et al. Carbonated Thin Liquid Significantly Decreases the Incidence of Spillover, Delayed Pharyngeal Response and Laryngeal Penetration Compared to Non-Carbonated Thin Liquids. Dysphagia 2001: 16: 146-150.

Saravou K, Walshe M. Effects of Carbonated Liquids on Oropharyngeal Swallowing Measures in People with Neurogenic Dysphagia. Dysphagia(2012) 27: 240-250.

Miura, Yutaka, et al. “Effects of taste solutions, carbonation, and cold stimulus on the power frequency content of swallowing submental surface electromyography.” Chemical senses 34.4 (2009): 325-331.

Course Alert-Head and Neck Cancer

head and neck cancder

Northern Speech Services is offering a new course on head and neck cancer entitled:  Head and Neck Cancer Across the Continuum of Care: Addressing Swallowing Challenges.  The course is taught by Paula Sullivan who is an expert in dysphagia in the cancer population.

Per the NSS website:

This comprehensive online course will provide the participant an in-depth examination of head and neck cancer, its presentation, functional sequelae, evaluation approaches, treatment options, and provide an evidence-based approach of optimal patterns of care for head and neck patients with swallowing dysfunction.  Types of treatment for head and neck cancer and their impact on swallowing and communication function will be described, including both surgical and organ preservation. 

Assessment and evidence-based practice relevant to the head and neck cancer population will provide support for the practitioner in developing a holistic approach to rehabilitation which will optimize functional outcomes and, most importantly, quality-of-life.  Video presentation will be an integral part of this course.  By the completion of this course, the participant will possess a comprehensive understanding of dysphagia management in this challenging and rewarding population. Offered for 0.9 ASHA CEUs – 9 contact hours. 

This is definitely a course on my to-take list!

Has anyone taken this course yet?  If so, let us know what you thought!

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

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.

Swallowing Exercise Aid (SEA)

I saw a tweet about this new Swallowing Exercise Aid yesterday.  I was extremely curious and decided to check out the article.

We’ve had some new research come out on the Chin Tuck Against Resistance (CTAR) and Jaw Opening Against Resistance (JOAR) as well as Isometric Progress Resistive Oropharyngeal Therapy (IPRO).  The common theme here is resistance.

Kraaijenga, SAC, et al.  Effects of Strengthening Exercises on Swallowing Musculature and Function in Senior Healthy Subjects:  A Prospective Effectiveness and Feasibility Study.  Dysphagia (2015) DOI:  10.1007/s00455-015-9611-8.  

This article looked at using a Swallowing Exercise Aid (SEA) in connection with 3 exercises (CTAR, JOAR and effortful swallow with resistance.)  

Ten healthy senior males with a median age of 60 were used in the study.  Inclusion criteria included absence of dysphagia or history of dysphagia.  

Exercises were completed 3x/day for 6 weeks including CTAR, JOAR and effortful swallow with resistance (swallowing with the mandible down and mouth closed).  The SEA device used was the Therabite Jaw Mobilization device with a Therabite Active Band.  The SEA device was used as resistance for all 3 exercises.  

Both CTAR and JOAR were completed isokinetically and isometrically.  For the isokinetic portion, each was completed 30 times with a 1 second muscle contraction.  For the isometric portion, each person was to complete static completion of the exercise for 60 seconds 3 times with a 60 second rest period between hold.  After an additional 60 second break, the person swallowed 10 consecutively using an effortful swallow while pushing the mandible down against the SEA and keeping the mouth closed.  Each exercise session was approximated to last 15 minutes.

Each participant was given written instructions on completion of the exercise.  They were sent 3 daily texts as reminders and used tally sheets to record exercise logs.  Participants were advised to stop exercises if they experienced pain or distress.

Outcomes were recorded prior to and 2 days after the 6 week exercise period.  Outcomes were measured by used of a dynamometer, the Iowa Oral Performance Instrument (IOPI), MRI and Videofluoroscopic Swallow Study (VFSS).  Outcomes measured included:

  • Maximum chin tuck and jaw opening strength.
  • Maximum tongue strength and endurance
  • Suprahyoid mass (Anterior Bell of the Digastric, Mylohyoid, Geniohyoid)
  • Hyoid bone displacement

Outcomes measured following 6 weeks of exercise indicated a significant increase in all of the above along with increased mouth opening and no pain.  Compliance with the program was reported at 86%.  

This program has huge implications for our patients with head and neck cancer.  I’m excited to see where this study may lead.

  

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

I’m back to the research!  I took a brief break last month.  Since I was covering 3 buildings and transitioning into the school system, I thought blogging about research might be pushing the limits a bit.  Not to mention creating slides for a presentation in Montana.

In looking into creating some new slides for a presentation, I came across an amazing article written by several amazing researchers in the field of dysphagia.  If you have access to the ASHA journals and are looking for some great evidence base for your dysphagia therapy, this is the place to begin.

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.